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The nurse is caring for a client in active labor with late decelerations on the monitor. What is the priority nursing intervention?
- A. Reposition the client to her side.
- B. Administer IV fluids.
- C. Apply oxygen via face mask.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Repositioning improves blood flow and oxygen delivery to the fetus during late decelerations.
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A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?
- A. Cephalic
- B. Transverse
- C. Posterior
- D. Frank breech
Correct Answer: A
Rationale: When the nurse locates the fetal heart tones above the client's umbilicus at midline, it indicates that the fetus is in a cephalic position. In this position, the baby's head is facing downward towards the birth canal, which is the optimal position for a vaginal delivery. This positioning is considered normal and favorable for childbirth.
Which component is important to include in the sexual history assessment to assess the risk of sexually transmitted infections (STIs)?
- A. current sexual activity
- B. reproductive plans
- C. education and counseling
- D. history of HIV testing
Correct Answer: A
Rationale:
Which finding during a prenatal visit is most concerning in a client at 32 weeks gestation?
- A. Blood pressure of 120/80 mmHg
- B. Mild lower back pain
- C. Weight gain of 2 pounds in one week
- D. Proteinuria of +2 on a urine dipstick
Correct Answer: D
Rationale: Proteinuria is a potential sign of preeclampsia, requiring evaluation.
The nurse is educating a client about kick counts. What instruction is most appropriate?
- A. Perform kick counts once a week.
- B. Lie on your back to count fetal movements.
- C. Count 10 fetal movements over 2 hours.
- D. Start counting movements at 36 weeks.
Correct Answer: C
Rationale: Counting 10 fetal movements within 2 hours is a standard method to monitor fetal well-being.
The nurse is caring for a client in labor receiving epidural anesthesia. What is the priority nursing assessment?
- A. Assess for bladder distention.
- B. Monitor maternal blood pressure.
- C. Evaluate fetal heart rate.
- D. Check for pain relief.
Correct Answer: B
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension, a common side effect of epidural anesthesia.