Try our free nursing testbanks today. click here to join
Teas 7 test, Hesi A2 and Nursing prep
Nursingprepexams LEARN. PREPARE. EXCEL!
  • Home
  • Nursing
  • TEAS
  • HESI
  • Blog
Start Studying Now

Take full exam for free

A nurse is caring for a client at term in labor.

 

The client states, “I can’t do this anymore.”. She reports rectal pressure and increasing nausea. SVE (sterile vaginal exam) performed: 9 cm, 100% effaced, +1 station.

A.

Encourage the client to continue pushing.

B.

Prepare the client for delivery.

C.

Administer pain relief as prescribed.

D.

Reassure the client and provide emotional support.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Encouraging the client to continue pushing is not appropriate at this stage. The client is 9 cm dilated, which indicates that she is in the transition phase of labor, not yet fully dilated and ready to push. Pushing at this stage could cause cervical swelling and delay progress.

 

Choice B rationale

 

Preparing the client for delivery is the most appropriate action. The client is in the transition phase of labor, with 9 cm dilation, 100% effacement, and +1 station. This indicates that delivery is imminent, and the nurse should prepare for the birth process.

 

Choice C rationale

 

Administering pain relief as prescribed may be considered, but it is not the priority action at this stage. The client is in the transition phase, and administering pain relief could interfere with the natural progression of labor. Non-pharmacological support may be more appropriate.

 

Choice D rationale

 

Reassuring the client and providing emotional support is important, but it is not the primary action at this stage. The nurse should focus on preparing for delivery while also providing support and reassurance.


Free Nursing Test Bank

  1. Free Pharmacology Quiz 1
  2. Free Medical-Surgical Quiz 2
  3. Free Fundamentals Quiz 3
  4. Free Maternal-Newborn Quiz 4
  5. Free Anatomy and Physiology Quiz 5
  6. Free Obstetrics and Pediatrics Quiz 6
  7. Free Fluid and Electrolytes Quiz 7
  8. Free Community Health Quiz 8
  9. Free Promoting Health across the Lifespan Quiz 9
  10. Free Multidimensional Care Quiz 10
Take full exam free

View Related questions

Correct Answer is A

Explanation

Choice A rationale

Monitoring the fetal heart rate is the next appropriate action. The fetal heart rate provides crucial information about the fetus’s well-being and can help identify any potential issues that may need further intervention.

Choice B rationale

Monitoring uterine contractions is important, but in this scenario, the client’s vital signs are stable, and there is no indication of labor. Therefore, monitoring the fetal heart rate takes precedence.

Choice C rationale

Amniotic fluid levels are important to monitor, but they are typically assessed through ultrasound rather than immediate bedside monitoring. The fetal heart rate provides more immediate information about the fetus’s condition.

Choice D rationale

Cervical dilation is relevant during labor, but there is no indication that the client is in labor based on the provided vital signs. Monitoring the fetal heart rate is more pertinent in this situation.

Correct Answer is B

Explanation

Choice A rationale

Dizziness can be a side effect of epidural anesthesia, but it is not as critical as hypotension. It should be monitored, but it does not require immediate reporting unless it is severe or accompanied by other symptoms.

Choice B rationale

Blood pressure of 88/52 mmHg indicates hypotension, which is a common and potentially serious side effect of epidural anesthesia. Hypotension can lead to decreased placental perfusion and fetal distress, so it requires immediate attention and reporting to the anesthesia provider.

Choice C rationale

A pain level of 1 on a 0 to 10 scale indicates that the epidural is effectively managing the client’s pain. This is a positive outcome and does not require reporting.

Choice D rationale

A pulse of 88 bpm is within the normal range for an adult and does not indicate any immediate concern that needs to be reported to the anesthesia provider.

Quick Links

Nursing Teas Hesi Blog

Resources

Nursing Test banks Teas Prep Hesi Prep Nursingprepexams Blogs
© Nursingprepexams.com @ 2019 -2026, All Right Reserved.