Question

A nurse is providing care to a client in labor. The nurse determines that the client is in the active phase based on which assessment finding(s)? Select all that apply.

Answer 1

Correct Answers:

Contractions every 2 to 5 minutes
Cervical dilation (dilatation) of 6 cm

Rationale :

⏱️Active labor typically produces regular contractions every 2 to 5 minutes.

📏The active phase begins at approximately 6 cm of cervical dilation.

🌊During this phase, contractions become stronger, longer, and more frequent.

👶These findings indicate progressive cervical change during the first stage of labor.

📌Core Message

The active phase of labor begins near 6 cm dilation with contractions occurring about every 2 to 5 minutes.

Answer 2

Correct Answers:

Heartburn
Hyperemic gums
Nausea
Reports of bloating

Rationale :

🍽️Progesterone slows gastrointestinal motility, which promotes abdominal fullness and bloating.

🔥Relaxation of the lower esophageal sphincter and delayed gastric emptying commonly cause heartburn.

🦷Increased estrogen raises gum vascularity, producing hyperemic or easily bleeding gums.

🤢Hormonal changes and slower digestion make nausea an expected pregnancy finding.

📌Core Message

Pregnancy commonly causes slower gastrointestinal motility, leading to heartburn, nausea, bloating, and vascular gums.

Answer 3

Correct Answers:

Parents who both work outside of the home
Single parents
Parents with a low level of support within the family

Rationale :

🛟Limited family support can reduce access to supervision and safety resources.

🏘️Government-subsidized housing can indicate low socioeconomic status, which is associated with greater childhood injury risk.

👤Single-parent families may experience increased financial demands and fewer available caregivers.

🤝These groups benefit from targeted education about water safety, bicycle helmets, and supervision.

📌Core Message

Injury-prevention teaching should prioritize families experiencing low support, socioeconomic disadvantage, or single parenthood.

Answer 4

Correct Answers:

Blood pressure 90/50 mm Hg

Rationale :

🩺A blood pressure of 90/50 mm Hg indicates significant postpartum hypotension.

💧Hypotension can result from dehydration, blood loss, or postpartum hemorrhage.

🩸The nurse should assess bleeding, pulse, dizziness, and uterine tone promptly.

🌡️Early investigation helps prevent worsening hypovolemia and circulatory instability.

📌Core Message

Postpartum hypotension requires further assessment for blood loss and hypovolemia.

Answer 5

Correct Answers:

Client having contractions every 5 minutes, cervical dilation (dilatation) 3 cm

Rationale :

⏳The latent or early phase occurs before the cervix reaches approximately 6 cm.

📏A cervical dilation of 3 cm is consistent with early labor.

〰️Contractions during this phase are usually less frequent than contractions in active labor.

🌱Contractions every 5 minutes with gradual cervical change indicate the latent phase.

📌Core Message

The latent phase involves early cervical change, usually below 6 cm, with less frequent contractions.

Answer 6

Correct Answers:

41.7

Rationale :

🧮The infusion contains 20 units in 1,000 mL.

💉At 125 mL/hr, the client receives 2.5 units each hour.

⏱️Converting units to milliunits produces 2,500 milliunits/hr.

✅Dividing by 60 minutes gives 41.7 milliunits/min.

📌Core Message

The prescribed oxytocin infusion delivers 41.7 milliunits per minute.

Answer 7

Correct Answers:

The client states, "My baby has my eyes and nose."

Rationale :

👶During the taking-in phase, the client begins claiming the newborn as part of the family.

🪞Identifying shared physical features demonstrates recognition and claiming behavior.

🫶The client remains relatively dependent while reviewing the birth experience.

🛏️Greater independence in newborn care develops later during the taking-hold phase.

📌Core Message

The taking-in phase includes dependence, reviewing the birth, and identifying the newborn as one’s own.

Answer 8

Correct Answers:

Valproic acid daily for epilepsy

Rationale :

⚠️Valproic acid can cause significant fetal harm when used during pregnancy.

🧬First-trimester exposure increases the risk of neural-tube defects and other congenital malformations.

💊The medication requires an immediate provider review to evaluate safer seizure management.

📞The client should not abruptly discontinue therapy because uncontrolled seizures can also endanger the client and fetus.

📌Core Message

Valproic acid exposure during early pregnancy requires urgent follow-up because of its teratogenic effects.

Answer 9

Correct Answers:

Count the respiratory rate of the neonate.

Rationale :

🌬️Fentanyl crosses the placenta and can enter the fetal circulation.

⏰The medication was administered only 19 minutes before birth, allowing little time for fetal clearance.

🫁Recent opioid exposure increases the newborn’s risk for respiratory depression.

🚼The nurse must immediately assess the neonate’s respiratory rate and breathing effort.

📌Core Message

After recent maternal fentanyl administration, the priority is assessing the neonate for respiratory depression.

Answer 10

Correct Answers:

"Choose whatever method you feel most comfortable with for pushing."

Rationale :

🗣️Spontaneous, patient-directed pushing is encouraged when labor is progressing normally.

🙌The laboring client should participate in choosing the most comfortable pushing technique.

🧘Open-glottis or closed-glottis pushing can be individualized according to comfort and effectiveness.

🧍Supporting maternal preferences promotes patient-centered care and can reduce unnecessary strain.

📌Core Message

Patient-directed pushing allows the client to use the method that feels most comfortable and effective.

1 :
A nurse is providing care to a client in labor. The nurse determines that the client is in the active phase based on which assessment finding(s)? Select all that apply.

2 :
A nurse is assessing a pregnant client at a routine checkup. When assessing the gastrointestinal tract, what does the nurse expect to find? Select all that apply.

4 :
When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding warrants further investigation?

5 :
A nurse is caring for several clients in labor. The nurse determines that which client is in the latent phase of labor?

6 :
A postpartum patient is prescribed oxytocin 20 units in 1,000 mL Lactated Ringer's to infuse at 125 mL/hr for uterine atony. How many milliunits per minute is the patient receiving? Show calculation.

7 :
A nurse is providing care to a postpartum client. The nurse determines that the client is in the taking-in phase based on which finding?

8 :
The nurse is caring for a client at 7 weeks' gestation during their first prenatal appointment. Upon reviewing the home medications, which finding indicates a need for follow-up by the nurse?

9 :
A pregnant client received fentanyl for pain management at 1145. The client gave birth at 1204, and oxytocin is running at 15 mUnits/min. At the time of birth, what is the nurse's priority intervention?

10 :
Which suggestion by the nurse about pushing would be most appropriate for a client in the second stage of labor?

1 : A nurse is providing care to a client in labor. The nurse determines that the client is in the active phase based on which assessment finding(s)? Select all that apply.

2 : A nurse is assessing a pregnant client at a routine checkup. When assessing the gastrointestinal tract, what does the nurse expect to find? Select all that apply.

4 : When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding warrants further investigation?

5 : A nurse is caring for several clients in labor. The nurse determines that which client is in the latent phase of labor?

6 : A postpartum patient is prescribed oxytocin 20 units in 1,000 mL Lactated Ringer's to infuse at 125 mL/hr for uterine atony. How many milliunits per minute is the patient receiving? Show calculation.

7 : A nurse is providing care to a postpartum client. The nurse determines that the client is in the taking-in phase based on which finding?

8 : The nurse is caring for a client at 7 weeks' gestation during their first prenatal appointment. Upon reviewing the home medications, which finding indicates a need for follow-up by the nurse?

9 : A pregnant client received fentanyl for pain management at 1145. The client gave birth at 1204, and oxytocin is running at 15 mUnits/min. At the time of birth, what is the nurse's priority intervention?

10 : Which suggestion by the nurse about pushing would be most appropriate for a client in the second stage of labor?

1 :
A nurse is providing care to a client in labor. The nurse determines that the client is in the active phase based on which assessment finding(s)? Select all that apply.

2 :
A nurse is assessing a pregnant client at a routine checkup. When assessing the gastrointestinal tract, what does the nurse expect to find? Select all that apply.

4 :
When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding warrants further investigation?

5 :
A nurse is caring for several clients in labor. The nurse determines that which client is in the latent phase of labor?

6 :
A postpartum patient is prescribed oxytocin 20 units in 1,000 mL Lactated Ringer's to infuse at 125 mL/hr for uterine atony. How many milliunits per minute is the patient receiving? Show calculation.

7 :
A nurse is providing care to a postpartum client. The nurse determines that the client is in the taking-in phase based on which finding?

8 :
The nurse is caring for a client at 7 weeks' gestation during their first prenatal appointment. Upon reviewing the home medications, which finding indicates a need for follow-up by the nurse?

9 :
A pregnant client received fentanyl for pain management at 1145. The client gave birth at 1204, and oxytocin is running at 15 mUnits/min. At the time of birth, what is the nurse's priority intervention?

10 :
Which suggestion by the nurse about pushing would be most appropriate for a client in the second stage of labor?