Questions and Answers | 2026/27 Updates |
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The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the
client is beginning the second stage of labor? Select all that apply.
1. The contractions are regular.
2. The membranes have ruptured.
3. The cervix is dilated completely.
4. The client begins to expel clear vaginal fluid.
5. The Ferguson reflex is initiated from perineal pressure. - ANSWER- -3. The cervix is
completely dilated
5. The Ferguson reflex is initiated from perineal pressure
The nurse in the labor room is caring for a client in the active stage of the first phase of labor.
The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip.
What is the most appropriate nursing action?
1. Administer oxygen via face mask.
2. Place the mother in a supine position.
3. Increase the rate of oxytocin intravenous infusion.
4. Document the findings and continue to monitor the fetal patterns. - ANSWER- -1.
Administer oxygen via face mask.
The nurse is performing an assessment of a client who is scheduled for cesarean delivery at 39
weeks of gestation. Which assessment finding indicates the need to contact the primary health
care provider (PHCP)?
1. Hemoglobin of 11 g/dL (110 mmol/L)
2. Fetal heart rate of 180 beats per minute
, 3. Maternal pulse rate of 85 beats per minute
4. White blood cell count of 12.000/mm3 (12 × 109/L) - ANSWER- -2. Fetal heart rate of 180
beats per minute
A client arrives at a birthing center in active labor. After examination, it is determined that her
membranes are still intact and she is at a −2 station. The primary health care provider prepares
to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of
the amniotomy? Select all that apply.
1. Less pressure on her cervix
2. Decreased number of contractions
3. Increased efficiency of contractions
4. The need for increased maternal blood pressure monitoring
5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord -
ANSWER- -3. Increased efficiency of contractions
5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
. The nurse is monitoring a client in labor. The nurse suspects umbilical cord
compression if which is noted on the external monitor tracing during a contraction?
1. Variability
2. Accelerations
3. Early decelerations
4. Variable decelerations - ANSWER- -4. Variable decelerations
A client in labor is transported to the delivery room and prepared for cesarean delivery. After
the client is transferred to the delivery room table, the nurse should place the client in which
position?
1. Supine position with a wedge under the right hip
2. Trendelenburg's position with the legs in stirrups