The nurse is in the process of admitting a multiparous woman to labor and delivery from the triage area.
One hour ago her vaginal exam was 5 cm dilated, 50% effaced, 1+ station.
While completing your review of her prenatal record and completing the admission Questionnaire, she tells you she has an urge to have a bowel movement.
The priority nursing intervention is to:

Reassure the client and rapidly complete the admission.

Assist your client to the bathroom to have a bowel movement.

Assess the fetal heart rate and uterine contractions with a routine tracing.

Assess her progress of labor with a vaginal exam as delivery is close.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Reassuring the client and rapidly completing the admission does not address the urgent symptom of an urge to have a bowel movement, which can indicate imminent delivery. Immediate assessment of labor progress is necessary.

Choice B rationale

Assisting the client to the bathroom to have a bowel movement may not be appropriate because the urge to defecate can signify the onset of the second stage of labor (pushing stage). Moving to the bathroom could risk an unattended delivery.

Choice C rationale

Assessing the fetal heart rate and uterine contractions with a routine tracing is important, but it does not directly address the urgent symptom of the urge to have a bowel movement. Vaginal exam takes priority to assess labor progress.

Choice D rationale

Assessing her progress of labor with a vaginal exam is the priority because the urge to have a bowel movement can signify that the baby is descending in the birth canal. This is the most immediate and necessary action to determine if delivery is imminent.

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Correct Answer is D

Explanation

Choice A rationale

Infection risk is generally higher postpartum rather than during the third stage of labor.

Choice B rationale

Fetal hypoxia is a concern during labor, but the third stage is more focused on delivery of the placenta.

Choice C rationale

Deep vein thrombosis is a longer-term postpartum concern, not specifically high risk in the third stage of labor.

Choice D rationale

Incomplete delivery of the placenta can lead to hemorrhage and is a primary concern in the third stage of labor.

A. A 1-hour post-prandial value of 110 mg/dL. B. A 3-hour glucose tolerance test fasting value of 80 mg/dL. C. A glucose challenge test-fasting value of 100 mg/dL and 2-hour value of 130 mg/dL. D. A 3-hour glucose tolerance test-fasting value of 98 mg/dL and 3-hour value of 190 mg/dL. .

Correct Answer is D

Explanation

Choice A rationale

A 1-hour post-prandial value of 110 mg/dL is within the normal range and does not indicate gestational diabetes.

Choice B rationale

A 3-hour glucose tolerance test fasting value of 80 mg/dL is normal and does not alone indicate gestational diabetes.

Choice C rationale

A glucose challenge test-fasting value of 100 mg/dL and a 2-hour value of 130 mg/dL do not meet the criteria for gestational diabetes diagnosis.

Choice D rationale

A 3-hour glucose tolerance test-fasting value of 98 mg/dL and a 3-hour value of 190 mg/dL indicate gestational diabetes due to elevated glucose levels.

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Naxlex Comprehensive Predictor Exams

The nurse knows that the third stage of labor has a high risk for which of the following complications?

Correct Answer is D

Explanation

The nurse knows that a diagnosis for gestational diabetes can be determined with which lab values?

Correct Answer is D

Explanation

A nurse is caring for a 34-year-old female client who is at 34 weeks of gestation in the antepartum unit. Exhibits Complete the following sentence using the list of options. Sentence: The priority intervention for the client is to dropdown and dropdown.

A 3800 gram newborn was admitted to the neonatal intensive care unit at 39 weeks with meconium aspiration. Metoclopramide 0.1 mg/kg every 12 hours was started. On hand is Metoclopramide 0.5 mg/ml. What is the appropriate dose the RN will administer in ml in 12 hours?

A nurse is caring for a client who is in premature labor and is receiving terbutaline.The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?

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While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital.The nurse's teaching was effective when the patient states that she will come when she:

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