A client in active labor is being prepared for epidural analgesia. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: The correct answer is D: Obtain a 30-minute electronic fetal monitoring (EFM) strip prior to induction. This is important to assess the fetal well-being and baseline status before initiating epidural analgesia. It helps in detecting any fetal distress or abnormalities that may be exacerbated by the epidural. A: Having the client sit upright with legs crossed is not recommended as it may interfere with the procedure and comfort of the client. B: Administering a 500 mL bolus of lactated Ringer's solution is not directly related to preparing for epidural analgesia. C: Informing the client about the duration of anesthetic effect is important, but ensuring fetal well-being through EFM monitoring is a priority before the procedure.

Correct Answer: D

Rationale: The correct answer is D: Variable decelerations. Variable decelerations are abrupt decreases in the fetal heart rate that coincide with contractions, indicating umbilical cord compression. This pattern can lead to fetal hypoxia and distress. Early decelerations (A) are gradual decreases in heart rate that mirror contractions and are considered benign. Accelerations (B) are increases in heart rate and are a reassuring sign of fetal well-being. Late decelerations (C) are gradual decreases in heart rate that occur after the peak of a contraction, indicating uteroplacental insufficiency.

Correct Answer: B

Rationale: The correct answer is B because implantation actually occurs around 6-10 days after fertilization, not after conception. This is a critical distinction as conception refers to the union of sperm and egg to form a zygote, while fertilization specifically refers to the fusion of the genetic material. Therefore, the statement by the newly licensed nurse is inaccurate and requires intervention. A: Fertilization typically occurs in the outer third of the fallopian tube, making this statement correct. C: Sperm can indeed remain viable in the woman's reproductive tract for 2 to 3 days, indicating this statement is accurate. D: Bleeding or spotting can indeed accompany implantation, making this statement correct. In summary, choice B is incorrect because implantation occurs around 6-10 days after fertilization, not conception. Choices A, C, and D are all correct statements related to conception and fertilization.

Correct Answer: D

Rationale: The correct answer is D, Deep tendon reflexes of +1. In preeclampsia, deep tendon reflexes are typically hyperactive, not diminished (+1). This indicates hyporeflexia, which is inconsistent with preeclampsia. A is consistent with preeclampsia, as mild edema is common. B is also consistent, as proteinuria is a hallmark sign. C is consistent, as elevated blood pressure is a key feature. Therefore, D is the only choice that does not align with the expected findings in preeclampsia.

Correct Answer: C

Rationale: The correct answer is C: Assess the odor of the amniotic fluid. This is the appropriate nursing action because the woman is at risk for chorioamnionitis due to the elevated temperature and ruptured membranes. Assessing the odor of the amniotic fluid can help in identifying signs of infection, as foul-smelling amniotic fluid may indicate chorioamnionitis. This can guide further interventions and management, such as initiating antibiotics. Choice A is incorrect as waiting 4 hours to recheck the temperature can delay necessary interventions for potential infection. Choice B is also incorrect as administering glucocorticoids is not the immediate priority in this situation. Choice D is incorrect as preparing for an emergency cesarean section is not warranted solely based on the client's temperature and ruptured membranes without further assessment for infection.

Correct Answer: C

Rationale: Rationale: Option C, having the client pant during the next contractions, is the correct answer. At 7 cm dilation with a sudden urge to push, it indicates possible fetal descent. Panting can help prevent rapid descent and reducing the risk of cervical edema or injury. It allows time for the cervix to dilate fully before pushing, preventing premature pushing and potential complications. Option A is not a priority at this stage. Option B is incorrect as observing for crowning might lead to premature pushing. Option D is not necessary as voiding is not the priority right now.

Correct Answer: D

Rationale: The correct answer is D: Hypotension. Epidural anesthesia can lead to hypotension due to vasodilation and sympathetic blockade, resulting in decreased blood pressure. This is a common complication that nurses should monitor for and manage promptly. Vomiting (A) is not a direct complication of epidural anesthesia. Tachycardia (B) is not typically associated with epidural anesthesia but may indicate other issues. Respiratory depression (C) is more commonly seen with opioids and not a typical complication of epidural anesthesia.

Correct Answer: D

Rationale: The correct sequence of maternal changes when planning to become pregnant is A) Amenorrhea, C) Goodell's sign, D) Quickening, and B) Lightening. Amenorrhea is the absence of menstruation, indicating possible pregnancy. Goodell's sign is the softening of the cervix and vagina. Quickening is the first fetal movements felt by the mother. Lightening occurs as the baby drops lower into the pelvis. This sequence reflects the chronological order of physiological changes during pregnancy. Choices A, B, and C do not follow the correct sequence of maternal changes as outlined in pregnancy progression.

Correct Answer: B

Rationale: The correct answer is B: Nipple line. This landmark is used for measuring newborn chest circumference as it ensures consistency in measurement and is a reliable reference point. The nipple line is anatomically consistent and easily identifiable, making it the ideal landmark for accurate measurements. Rationale: A: Sternal notch is not recommended for chest circumference measurement in newborns as it is not a consistent landmark and may vary among individuals. C: Xiphoid process is not suitable for chest circumference measurement as it is located at the lower end of the sternum and not commonly used for this purpose. D: Fifth intercostal space is not a recommended landmark for chest circumference measurement in newborns as it is not as reliable and consistent as the nipple line.