The nurse is caring for a gravida 7 para 5 client admitted 3 hours ago who is now 9 cm dilated, 90
Instruct client to reposition every 3 hours.
Instruct the client to push with the next contraction.
Provide initial labor education to the family.
Prepare supplies for the anticipated delivery.
The Correct Answer is D
The nurse must apply knowledge of labor stages and parity. Recognizing that a multiparous client in the transition phase of labor often progresses rapidly to delivery is essential for prioritizing preparation for the second stage of labor and birth.
Choice A rationale
Repositioning every three hours is too infrequent for a client in the transition phase. Furthermore, at 9 cm dilation, the priority is preparing for imminent birth rather than implementing a long-term comfort schedule for early labor.
Choice B rationale
Pushing before the cervix is completely dilated at 10 cm can cause cervical edema or lacerations. The client is currently 9 cm dilated, so instructing her to push now is premature and potentially harmful to the cervix.
Choice C rationale
Initial labor education should occur during the latent phase. By the time a client reaches 9 cm dilation, they are in the transition phase and unable to process complex education due to the intensity of labor.
Choice D rationale
A multiparous client (para 5) at 9 cm dilation is likely to progress to complete dilation and birth very quickly. Preparing delivery supplies immediately ensures that the room is ready for the safe arrival of the newborn..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Umbilical cord care focuses on preventing infection and promoting natural desiccation. Nurses apply principles of aseptic technique and health promotion to educate parents on identifying omphalitis and maintaining the cord site until the stump naturally separates from the neonate's abdomen.
Choice A rationale
Redness, edema, or foul smelling drainage are cardinal signs of omphalitis, a potentially serious infection. Parents must be taught to monitor the site closely and report these findings immediately to ensure prompt medical evaluation and antibiotic treatment.
Choice B rationale
The umbilical cord typically undergoes dry gangrene and falls off within 7 to 14 days after birth. Telling parents it takes a month is inaccurate and may cause unnecessary concern or delay the identification of delayed cord separation.
Choice C rationale
The diaper should be folded down below the umbilical stump. Keeping the cord outside the diaper prevents contamination from urine or feces and allows air exposure, which facilitates the drying process necessary for the cord to fall off.
Choice D rationale
The cord must be kept clean and dry to promote healing and separation. Moisture at the site encourages bacterial growth and delays the drying process. Current evidence based practice emphasizes dry cord care over the application of various liquids..
Correct Answer is D
Explanation
Management of labor induction requires continuous physiological monitoring to ensure maternal and fetal safety. Nurses must apply knowledge of uterine tachysystole and fetal oxygenation to prevent hypoxic injury. Establishing baseline data for uterine activity and fetal heart patterns is the primary prerequisite.
Choice A rationale
Administering large fluid boluses is not standard prior to oxytocin unless anesthesia is imminent. While hydration is important, preventing hypotension is more relevant to regional blocks than to the initiation of synthetic oxytocin for uterine contractions.
Choice B rationale
Patient education is a vital component of informed consent and nursing care. However, in an acute clinical setting, ensuring physiological safety through monitoring takes precedence over documentation of teaching before the medication is physically started.
Choice C rationale
Vertex cephalic presentation is the ideal longitudinal lie for vaginal delivery. Notifying the provider of malposition would be inaccurate as the fetus is correctly positioned. Holding the medication based on this assessment would be clinically inappropriate.
Choice D rationale
Oxytocin carries a high risk for uterine hyperstimulation. Continuous electronic fetal monitoring is essential to establish a baseline fetal heart rate and evaluate contraction frequency, ensuring the fetus tolerates the induced stress of labor contractions.
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