The client in active labor has moderate to strong contractions occurri

Maternal NCLEX

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Question 1 of 5.

The client in active labor has moderate to strong contractions occurring every 2 minutes and lasting 60 to 70 seconds. The client states extreme pain in the small of her back. Her abdomen reveals a small depression under the umbilicus. Which fetal position should the nurse document?

A. Occiput anterior

B. Occiput posterior

C. Left occiput anterior

D. Right occiput anterior

Explanation: An occiput posterior position is characterized by intense back pain (back labor). A depression under the umbilicus occurs as a result of the posterior shoulder. When a fetus presents anterior, it is uncommon for the mother's chief symptom to be back pain, and the uterus should appear smooth.

Question 2 of 5.

The nurse correctly explains that the bleeding is the result of sloughing of which structure?

A. Endometrium

B. Myometrium

C. Epimetrium

D. None of the above

Explanation: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.

Question 3 of 5.

On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?

A. 5 months

B. 6 months

C. 7 months

D. 8 months

Explanation: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.

Question 4 of 5.

The nurse correctly assists the client into which position?

A. Lithotomy

B. Prone

C. Sims'

D. Trendelenburg's

Explanation: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.

Question 5 of 5.

Which response by the nurse is most accurate?

A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.

B. Hepatitis B surface antigen (HBsAg) test can detect this defect.

C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.

D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.

Explanation: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.