Susan Wilson (2): A 26-year-old primigravida during labor and delivery Comprehensive Questions and
ANswers LATEST 2025
Based on Susan's assessment data and history, you identify which of the following as a priority
nursing diagnosis for Susan at this time? - correct answer Deficient Fluid Volume related to
inadequate intake of liquids
With regard to Susan's rupture of membranes, which questions are important? - correct answer
"What was the color of the fluid?"
"What time did your 'water break'?"
Based on your assessment, you determine that the fetus is in a/an - correct answer CEPHALIC
Based on your assessment, you position the ultrasound transducer on Susan's abdomen at the:
- correct answer right lower quadrant
Fetal heart rate increases can be associated with a variety of factors. These include:
Select all that apply (there are 4 correct answer s). - correct answer maternal fever or infection
fetal anemia
the mother receiving the drug Brethine (terbutaline)
the mother receiving the drug Yutopar (ritodrine) C
Susan has been monitored for 15 minutes. Which of the following actions on your part is
indicated? - correct answer Continue to monitor the fetal heart rate
To measure the frequency of Susan's contractions you examine a 10-minute strip and: - correct
answer determine the time from the beginning of one contraction to the beginning of the next
You perform a vaginal exam to check for shortening and thinning of Susan's cervix. This is called
- correct answer EFFACEMENT
You also determine that the fetus is at zero station. John is curious about what you mean by
"the fetus is at zero station." Your response is based on the knowledge that zero station means
that: - correct answer the baby's presenting part is at the level of the mother's ischial spines
Based on your assessment of Susan (3 cm dilated, 80% effaced, fetus at zero station) and your
interpretation of her data, you determine that she is now in which stage of labor? - correct
answer Stage one
Susan has decided to rest in bed for a while. Which of the following positions are acceptable?
Select all that apply (there are 2 correct answer s). - correct answer Left lateral
Right lateral
You remind Susan that it is important for her to try to urinate every two hours. The rationale for
this is that a distended bladder can:
, Susan Wilson (2): A 26-year-old primigravida during labor and delivery Comprehensive Questions and
ANswers LATEST 2025
Select all that apply (there are 3 correct answer s). - correct answer cause difficulty in voiding
after delivery
interfere with fetal descent
increase the pain associated with uterine contractions
In response to the order for Stadol (butorphanol tartrate), which of the following is indicated? -
correct answer Administer the Stadol (butorphanol tartrate) as ordered
You determine that Susan is now in which phase of stage one labor? - correct answer Active
phase
A number of factors may affect the length of time a woman's labor will last. These include:
Select all that apply (there are 3 correct answer s). - correct answer the parity of the mother
maternal activity and position
fetal position and size
What is the best nursing action to take at this time? - correct answer Suggest that John take a
short break and have another family member coach Susan temporarily
You identify this as a/an_________deceleration - correct answer early
You know, that early deceleration is caused by: - correct answer compression of the fetal head
The anesthesiologist performs the epidural procedure and Susan begins to feel almost
immediate relief from painful contractions. You know that a priority nursing intervention is to: -
correct answer frequently monitor Susan's blood pressure for hypotension
Because Susan had an epidural she has not exhibited some of the signs/behaviors that
otherwise characterize the transition phase. These include:
Select all that apply (there are 4 correct answer s). - correct answer physical shaking
reluctance to be touched
amnesia between contractions
diaphoresis
You examine a recent strip from the fetal monitor. The abnormal fetal heart rate pattern you
observe is interpreted as a________deceleration - correct answer late
In response to the occurrence of a late deceleration, which of the following actions should be
carried out FIRST? - correct answer Turn Susan on her left side
At this point, which of the following would be appropriate advice for Susan?
ANswers LATEST 2025
Based on Susan's assessment data and history, you identify which of the following as a priority
nursing diagnosis for Susan at this time? - correct answer Deficient Fluid Volume related to
inadequate intake of liquids
With regard to Susan's rupture of membranes, which questions are important? - correct answer
"What was the color of the fluid?"
"What time did your 'water break'?"
Based on your assessment, you determine that the fetus is in a/an - correct answer CEPHALIC
Based on your assessment, you position the ultrasound transducer on Susan's abdomen at the:
- correct answer right lower quadrant
Fetal heart rate increases can be associated with a variety of factors. These include:
Select all that apply (there are 4 correct answer s). - correct answer maternal fever or infection
fetal anemia
the mother receiving the drug Brethine (terbutaline)
the mother receiving the drug Yutopar (ritodrine) C
Susan has been monitored for 15 minutes. Which of the following actions on your part is
indicated? - correct answer Continue to monitor the fetal heart rate
To measure the frequency of Susan's contractions you examine a 10-minute strip and: - correct
answer determine the time from the beginning of one contraction to the beginning of the next
You perform a vaginal exam to check for shortening and thinning of Susan's cervix. This is called
- correct answer EFFACEMENT
You also determine that the fetus is at zero station. John is curious about what you mean by
"the fetus is at zero station." Your response is based on the knowledge that zero station means
that: - correct answer the baby's presenting part is at the level of the mother's ischial spines
Based on your assessment of Susan (3 cm dilated, 80% effaced, fetus at zero station) and your
interpretation of her data, you determine that she is now in which stage of labor? - correct
answer Stage one
Susan has decided to rest in bed for a while. Which of the following positions are acceptable?
Select all that apply (there are 2 correct answer s). - correct answer Left lateral
Right lateral
You remind Susan that it is important for her to try to urinate every two hours. The rationale for
this is that a distended bladder can:
, Susan Wilson (2): A 26-year-old primigravida during labor and delivery Comprehensive Questions and
ANswers LATEST 2025
Select all that apply (there are 3 correct answer s). - correct answer cause difficulty in voiding
after delivery
interfere with fetal descent
increase the pain associated with uterine contractions
In response to the order for Stadol (butorphanol tartrate), which of the following is indicated? -
correct answer Administer the Stadol (butorphanol tartrate) as ordered
You determine that Susan is now in which phase of stage one labor? - correct answer Active
phase
A number of factors may affect the length of time a woman's labor will last. These include:
Select all that apply (there are 3 correct answer s). - correct answer the parity of the mother
maternal activity and position
fetal position and size
What is the best nursing action to take at this time? - correct answer Suggest that John take a
short break and have another family member coach Susan temporarily
You identify this as a/an_________deceleration - correct answer early
You know, that early deceleration is caused by: - correct answer compression of the fetal head
The anesthesiologist performs the epidural procedure and Susan begins to feel almost
immediate relief from painful contractions. You know that a priority nursing intervention is to: -
correct answer frequently monitor Susan's blood pressure for hypotension
Because Susan had an epidural she has not exhibited some of the signs/behaviors that
otherwise characterize the transition phase. These include:
Select all that apply (there are 4 correct answer s). - correct answer physical shaking
reluctance to be touched
amnesia between contractions
diaphoresis
You examine a recent strip from the fetal monitor. The abnormal fetal heart rate pattern you
observe is interpreted as a________deceleration - correct answer late
In response to the occurrence of a late deceleration, which of the following actions should be
carried out FIRST? - correct answer Turn Susan on her left side
At this point, which of the following would be appropriate advice for Susan?
