Maternal NCLEX Practice Questions | Nurselytic

Questions 49

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Maternal NCLEX Practice Questions Questions

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Question 1 of 5

The laboring multigravida client’s last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?

Correct Answer: D

Rationale: The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife. During labor, rectal pressure is usually not due to the need for a bowel movement because intestinal motility decreases.

Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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Similar Questions

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