NR-327 Maternal-Child Nursing - Set 3 - Part 1

Correct Answer: Stay, give brief directions, and normalize her feelings

Transition is frightening and the nurse does not leave. Short one step instructions, praise and the reminder that this is the shortest phase help her keep working through each contraction. Option b is incorrect because honoring the request to be alone abandons her at the hardest stretch of labor. Her words express distress, not a considered preference for solitude at this moment. Option c is incorrect because detailed explanations overload a client who can barely follow one sentence right now. Complex teaching belongs to early labor, when she is alert and able to listen. Option d is incorrect because pushing before the cervix opens fully swells the rim and can tear it. The nurse coaches blowing or panting through the urge until dilation is complete.

Correct Answer: Catheterize her according to unit protocol

The block removes bladder sensation and weakens the detrusor, so the client cannot feel fullness. A distended bladder impedes fetal descent and later contributes to uterine atony, making catheterization the correct response. Option a is incorrect because waiting for an urge that the block has abolished guarantees continued distension. Bladder assessment with an epidural relies on palpation every two hours rather than on what the client feels. Option b is incorrect because more anesthetic deepens the very sensory and motor loss behind the retention. Rate changes belong to anesthesia anyway, and the bladder would simply keep filling under a denser block. Option d is incorrect because running water works by prompting a reflex that requires intact sensation and pelvic floor control. Neither is present here, and the delay lets the full bladder go on obstructing descent.

Correct Answer: The fetus is currently well oxygenated

An acceleration of fifteen beats above baseline lasting fifteen seconds reflects an intact, oxygenated central nervous system, and its presence reliably rules out metabolic acidemia at that moment. Option b is incorrect because acidemia develops when oxygen delivery is interrupted long enough for lactate to build; a fetus able to accelerate its heart rate is demonstrating the opposite. Option c is incorrect because cord compression produces abrupt drops below the baseline rather than rises above it, and those variable decelerations call for a position change instead. Option d is incorrect because oxygen by mask belongs to intrauterine resuscitation for a worrying pattern; accelerations need no intervention at all beyond documenting them and continuing routine surveillance.

Correct Answer: Absent variability with recurrent late decelerations

Absent variability paired with recurrent lates defines a Category III tracing and correlates with abnormal acid base status. The nurse begins the full bundle at once and calls the provider urgently. Option a is incorrect because wide swings above twenty five beats are indeterminate rather than abnormal, and dips that mirror contractions never disqualify a strip. This pairing warrants watching, not urgency. Option b is incorrect because preserved variability tells the nurse this fetus is handling the cord squeezes without acidemia. The pattern is Category II and usually answers to a simple position change. Option d is incorrect because a baseline in range with reduced but detectable fluctuation is indeterminate. The nurse looks for a sleep cycle or medication and tries stimulation before assuming hypoxia.

Correct Answer: Rest and save this energy for labor ahead

A sudden burst of energy, often called nesting, commonly appears a day or two before labor as progesterone falls. Teaching her to conserve it prevents her from starting a long labor already exhausted. Option a is incorrect because infection announces itself with fever, chills, malaise and often uterine tenderness, not with a wave of productive energy. Nothing in her call suggests an infectious process. Option b is incorrect because heavy housework does not bring labor on any faster, and it spends the reserve she will need. Encouraging more scrubbing sets her up for exhaustion once contractions become demanding. Option c is incorrect because an energy spurt is an expected premonitory change rather than a warning finding. Calling the provider about it adds no safety and may alarm a client who is doing fine.

Correct Answer: Category II, requiring resuscitation and close surveillance

Recurrent late decelerations rule out Category I, but Category III demands absent variability. Moderate variability keeps this tracing indeterminate, so the nurse resuscitates, corrects any cause and re-evaluates continuously. Option a is incorrect because students upgrade this pattern constantly; the abnormal tier requires variability that cannot be detected at all, and this fetus is still swinging six to twenty five beats. Option b is incorrect because a normal tracing must have no late and no variable decelerations at all. One qualifying criterion has failed here, which moves the strip out of the reassuring tier. Option d is incorrect because the indeterminate label is not permission to stand still. Recurrent lates mean the placenta is struggling, so the nurse turns her, stops oxytocin, boluses fluid and reassesses.

Correct Answer: The head is well flexed, presenting the smallest diameter

The triangular posterior fontanelle sits at the occiput, so palpating it centrally means the chin is tucked onto the chest. Full flexion presents the suboccipitobregmatic diameter, the smallest one that has to clear the pelvis. Option b is incorrect because an extended head brings the diamond shaped anterior fontanelle within easy reach of the examining finger. The occipitomental diameter that follows extension is the widest and often obstructs birth. Option c is incorrect because a military attitude holds the head neutral, and both fontanelles tend to be reachable at about the same level. That neutral posture presents the wider occipitofrontal diameter. Option d is incorrect because breech palpation yields soft buttocks, the anal opening and possibly a foot, never a cranial suture line. Fontanelles can only be identified when the head presents at the cervix.

Correct Answer: Drowsiness, nausea, and mild dizziness

Systemic opioids take the edge off contraction pain while producing sedation, nausea, dizziness, and itching. The client rests between contractions but still feels the contractions, which is the expected rather than a failed response. Option a is incorrect because opioids more often produce a mild fall in blood pressure with a stable or slightly raised pulse. A slow heart rate with a widening pulse pressure points elsewhere entirely. Option b is incorrect because a rigid tender uterus with dark bleeding signals placental abruption. Premature separation of the placenta is a bleeding emergency that must never be attributed to an analgesic dose. Option c is incorrect because tingling around the mouth with a metallic taste belongs to local anesthetic systemic toxicity, seen when a regional block drug reaches the bloodstream. Intravenous opioid analgesia does not cause it.

Correct Answer: Turn her onto her unblocked left side

Gravity carries anesthetic toward the dependent side, so lying on the unmedicated side helps the solution spread there. The nurse then checks the pump, catheter, and connections and calls anesthesia if pain persists. Option a is incorrect because replacement is a later step, taken once simple measures fail. Anesthesia is certainly called, but repositioning and a check of the pump and tubing come before any decision to resite. Option b is incorrect because extra volume treats hypotension, and nothing in this picture points to a falling pressure. Fluid cannot redistribute an anesthetic that has pooled along one side of the epidural space. Option d is incorrect because sitting upright pulls the solution caudally toward the sacral roots rather than across to the side that is still painful. The left sided gap in the block would remain untouched.

Correct Answer: The presenting part has descended past the spines

Station is measured from the ischial spines, with negative numbers above them and positive numbers below. Moving from minus two to plus one shows the presenting part has descended through the midpelvis. Option b is incorrect because the numbers moved in the direction of progress, not retreat. Ascent would be charted as a change toward larger negative values, such as minus two drifting to minus four. Option c is incorrect because station and dilation are separate entries in the examination triad. Descent can occur while the cervix stays unchanged, so these numerals say nothing about how far the os has opened. Option d is incorrect because attitude describes how the fetus is folded, judged by palpating sutures and fontanelles. A shift in station reports travel through the pelvis and says nothing about flexion.

Correct Answer: Stroking the abdomen lightly in rhythmic circles

Effleurage is light rhythmic fingertip stroking of the abdomen, timed with the contraction, and it eases the dull diffuse discomfort of early first stage labor by stimulating large touch fibers. Option a is incorrect because firm sacral pressure describes counterpressure, the measure reserved for the lumbosacral pain of an occiput posterior fetus. Effleurage never involves that degree of force against the back. Option b is incorrect because kneading muscle groups is general massage. It relieves overall tension and anxiety, yet it targets neither the abdominal wall nor the rhythm of the contraction that effleurage follows. Option d is incorrect because the knee press pushes the femurs toward the hips to tilt the pelvis off the sacrum. That maneuver treats back labor and has no role in early abdominal cramping.

Correct Answer: Measure the client's temperature

Maternal fever and chorioamnionitis are the most common causes of fetal tachycardia, and the fetal rate often rises before the mother's temperature does. Checking it points straight at the cause. Option b is incorrect because resting tone matters when contractions are crowded or the uterus stays firm, which produces decelerations rather than a sustained rise in the baseline rate. Option c is incorrect because a falling blood pressure shows itself as late decelerations or bradycardia, not as a climbing baseline; pressure is worth knowing but does not explain this finding. Option d is incorrect because cervical change tells the nurse how labor is progressing and nothing about why the fetal heart is racing. The tachycardia needs a cause identified, not a progress check.

Correct Answer: Encourage walking and complete the admission assessment

Latent labor is the time for orientation, history taking, rapport and movement. Walking and position changes shorten this phase, and she still has the energy and focus to take in teaching. Option a is incorrect because constant coaching is unnecessary while contractions remain mild and widely spaced. Saving that intensity for active labor keeps both the client and the nurse from burning out early. Option b is incorrect because setting up for delivery belongs near full dilation or once the perineum bulges. Two centimeters leaves many hours of cervical work before any of that equipment is needed. Option c is incorrect because uninterrupted presence is the standard during transition and pushing, not while she is comfortable and talkative. Ambulation would also become impossible if the nurse never left the room.

Correct Answer: Auscultate the fetal heart rate and pattern

Fetal status leads every labor admission. The nurse confirms that the fetus is tolerating labor before turning to paperwork, history or the birth plan, because a compromised fetus changes everything else. Option a is incorrect because prenatal records supply blood type, group B streptococcus status and antibody results that shape later care. Reading a chart tells the nurse nothing about the fetus right now. Option c is incorrect because gravidity, parity and dating belong to the admission database gathered after fetal wellbeing is confirmed. History taking is important yet carries no urgency in the opening minutes. Option d is incorrect because violence screening does require a private moment with the partner out of the room. Safety questions still follow the check that tells the nurse whether the fetus is stable.

Correct Answer: Helping a client turn to her side

Assisting with a position change is routine comfort and safety work that needs no nursing judgment. Reading the strip, titrating medication and choosing when to escalate all stay with the registered nurse. Option a is incorrect because classifying a tracing means weighing baseline, variability and deceleration type against the criteria. That analysis sits squarely inside the nursing scope of practice and cannot be handed off. Option b is incorrect because titrating an intravenous medication in response to a contraction pattern is an assessment driven decision. Assistive personnel may not start, stop or change any infusion rate. Option d is incorrect because judging when a pattern warrants escalation requires interpretation of the whole clinical picture. An assistant can report what a client says, but not decide what a strip means.

Correct Answer: A small weight loss before labor

A loss of one to three pounds is common in the last days before labor as progesterone falls and fluid shifts. It accompanies lightening, cervical ripening, bloody show and a burst of energy. Option b is incorrect because weight typically drops slightly rather than climbing as term arrives. Rapid gain of several pounds would instead raise concern about fluid retention linked to a hypertensive disorder. Option c is incorrect because fetal movement continues right up to labor, though the pattern may feel different once the head engages. Absent movement is a danger sign demanding prompt evaluation, never an expected change. Option d is incorrect because lightening drops the presenting part into the pelvis, so fundal height often measures slightly lower. A rising fundus near term would suggest something other than normal preparation for birth.

Correct Answer: "I have to palpate to judge the strength of contractions."

The tocodynamometer senses abdominal tightening, so it reports only when a contraction starts and stops. Strength and resting tone come from the nurse's hands or from an intrauterine pressure catheter. Option a is incorrect because the figure on the toco panel is a relative pressure reading that shifts with maternal position and body build. Intensity is graded as mild, moderate or strong by palpation. Option c is incorrect because resting tone in millimeters of mercury requires a catheter inside the uterine cavity; an external belt cannot report what the pressure is between contractions. Option d is incorrect because labor progress is judged by cervical change and fetal descent, not by a number on the strip. Frequency and duration are all the belt actually contributes.

Correct Answer: Assist her to empty her bladder

That mass is a distended bladder, and a full bladder physically blocks the presenting part from descending. Emptying it is an independent nursing action that often restarts progress within a contraction or two. Option a is incorrect because an operative birth is considered only after correctable causes of arrest have been ruled out. Removing urine costs nothing and may make instruments unnecessary altogether. Option b is incorrect because more oxytocin drives contractions against a mechanical obstruction that is sitting in the pelvis. Stronger powers cannot push a head past a bladder full of urine. Option c is incorrect because lying flat compresses the vena cava and narrows the pelvic outlet at the same time. Upright and squatting postures would serve descent far better than this one.

Correct Answer: It replaces a wider diameter with a narrower one

Flexion swaps the occipitofrontal diameter of about eleven centimeters for the suboccipitobregmatic diameter of roughly nine, giving the head its most efficient shape for the remaining descent through the pelvis. Option a is incorrect because the bony pelvis has fixed dimensions that no fetal movement can enlarge. Maternal squatting or an upright posture can open the outlet slightly, but flexion works on the fetal head instead. Option c is incorrect because internal rotation, not flexion, turns the head, and it carries the occiput forward under the symphysis rather than back toward the sacrum. Posterior rotation would create back labor. Option d is incorrect because engagement is a separate cardinal movement, marked by the biparietal diameter clearing the inlet and the presenting part reaching zero station. Flexion changes shape rather than proving descent.

Correct Answer: Presenting part charted at zero station

Engagement means the widest diameter has passed the pelvic inlet, and clinically that corresponds to the presenting part reaching the ischial spines. Charting zero station is the bedside marker examiners use. Option a is incorrect because minus three places the presenting part three centimeters above the spines, still well short of the level that defines engagement. Descent must continue before that term applies. Option b is incorrect because a freely ballottable presenting part bounces under the examiner's hand, showing it has not settled into the pelvis. Pawlik's grip finds a fixed part once engagement has occurred. Option d is incorrect because minus one still sits above the ischial spines, so the widest diameter has not cleared the inlet. Engagement is charted only when the presenting part reaches the spines themselves.