Nokea
The nurse is assessing fetal presentation in a multiparous client. The illustration below indicates which of the following types of presentation?
- A. Frank breech.
- B. Complete breech.
- C. Footling breech.
- D. Vertex.
Correct Answer: D
Rationale: Without the illustration, the context suggests a typical presentation for a multiparous client, which is most likely vertex (head-down), the most common and favorable for vaginal delivery.
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Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first:
- A. Warm the temperature of the room by a few degrees.
- B. Increase the rate of intravenous fluid administration.
- C. Obtain an order for an intramuscular antiemetic medication.
- D. Assess the client's cervical dilation and station.
Correct Answer: D
Rationale: Nausea, chills, perspiration, and irritability are signs of the transition phase (8–10 cm dilation). Assessing cervical dilation and station confirms progression and guides care. Warming the room, increasing fluids, or administering antiemetics are secondary.
The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push, the nurse should assess:
- A. Fetal heart rate variability.
- B. Cervical dilation again.
- C. Status of membranes.
- D. Bladder status.
Correct Answer: D
Rationale: A full bladder can impede fetal descent and increase discomfort during pushing. Assessing bladder status (and catheterizing if needed) is critical before pushing begins. Fetal heart rate, dilation, and membrane status should already be monitored but are not the priority at this moment.
A nurse is teaching a client about the fertility awareness method. Which of the following instructions should the nurse include?
- A. Track basal body temperature and cervical mucus daily.
- B. Avoid intercourse throughout the entire menstrual cycle.
- C. Use this method if you have irregular periods.
- D. Monitor ovulation with a home pregnancy test.
Correct Answer: A
Rationale: Tracking basal body temperature and cervical mucus daily is essential for the fertility awareness method to identify fertile days. Intercourse is avoided only during fertile periods, the method is less reliable with irregular periods, and pregnancy tests do not monitor ovulation.
A client is considering the fertility awareness method. Which of the following client statements indicates understanding?
- A. I will track my basal body temperature daily.
- B. I can use this method with irregular cycles.
- C. I will monitor ovulation with a pregnancy test.
- D. I will avoid intercourse throughout the cycle.
Correct Answer: A
Rationale: Tracking basal body temperature daily is a key component of the fertility awareness method. It is less reliable with irregular cycles, pregnancy tests do not monitor ovulation, and intercourse is avoided only during fertile periods.
When developing the plan of care for a multiparous client in active labor who receives an epidural anesthetic, which of the following would the nurse anticipate that the physician will order if the client develops moderate hypotension?
- A. Ephedrine sulfate.
- B. Epinephrine (Adrenalin Chloride).
- C. Methylergonovine (Methergine).
- D. Atropine sulfate.
Correct Answer: A
Rationale: Ephedrine sulfate is commonly used to treat epidural-related hypotension by increasing blood pressure through vasoconstriction and cardiac stimulation. Epinephrine is for emergencies, methylergonovine treats uterine atony, and atropine addresses bradycardia.