CORRECT WELL DETAILED
ANSWERS|LATEST!!!!2025/2026|GUARANTEED
The nurse is reviewing fetal circulation with a nursing student. The nurse concludes the
student understands the teaching when which statements are made? (select all that apply)
- the umbilical cord contains two veins and one artery
- umbilical artery blood has the highest oxygenation
- fetal oxygenation occurs through the placenta
- the foramen ovale is open in the fetal state
- blood flows from the placenta to the fetal heart - ANSWER - fetal oxygenation occurs
through the placenta
- the foramen ovale is open in the fetal state
- blood flows from the placenta to the fetal heart
The laboring client at term states to the nurse, "i think my water just broke." the nurse
observes a shiny, gelatinous, rope-like structure protruding from the client's vaginal area.
What is the next nursing action?
- call for help
- place the client in knee chest position
- increase the mainline IV fluids
- reassure the client - ANSWER place the client in knee chest position
(rationale: this client is showing signs of an obstetric emergency of a prolapsed umbilical
cord. Compression of the cord can lead to fetal anoxia. Placing the client in knee-chest
position reduces the weight of the presenting part off of the cord. The nurse will need to
complete the remaining options, but oxygenation of the fetus takes priority)
1
,A client at 39 weeks gestation overhears her health care provider say to the nurse, "her
bishop score is 10." the client asks the nurse, "what does that mean?" what is the nurse's
best response?
- "your baby is in a good position to deliver."
- "your cervix is ready for labor."
- "labor will start in the next 24 hours."
- "your amniotic sac will rupture soon." - ANSWER "your cervix is ready for labor."
(rationale: the bishop score is a representation of cervical consistency, dilation, position, and
effacement, and of station of the presenting part. The lowest score is 0, indicating the cervix
is not ready to open. The highest score is 13. While the score includes the placement of the
presenting part in relationship to the ischial spines, it is not reflective of fetal positioning. It
is nonpredictive of onset of labor or rupture of membranes)
A mother who is breastfeeding her baby receives instructions from the nurse. Which
instructions are most effective in preventing nipple soreness? (select all that apply.)
- massage a small amount of medical grade lanolin into the nipple
- increase nursing time gradually over several days
- ensure that the baby is positioned correctly for latching on
- manually express a small amount of milk before nursing
- wear a cotton bra with nonbinding support - ANSWER - massage a small amount of
medical grade lanolin into the nipple
- ensure that the baby is positioned correctly for latching on
A client at 36 weeks gestation presents to labor and delivery and states to the nurse, "i have
been leaking fluid for about 2 days now. At first I thought it was urine. Now, I am not so
sure." which nursing actions are most appropriate for this client? (select all that apply.)
- assess maternal vital signs
- place an electronic fetal monitor
- place a peri pad
- assess the fluid for a foul odor
2
, - obtain a maternal blood glucose
- obtain a complete blood count - ANSWER - assess maternal vital signs
- place an electronic fetal monitor
- assess the fluid for a foul odor
- obtain a complete blood count
(rationale: until rupture of membranes has been ruled out, the nurse must provide care as if
they are ruptured. Since it has been 2 days with leaking fluid, the client may have developed
chorioamnionitis)
The nurse is providing care to a laboring client at term. Which client statement indicates to
the nurse that the client is entering stage two of labor?
- "I feel the baby coming out NOW!"
- "I feel like my water just broke"
- "I feel my baby moving around a lot"
- "I feel like I have to push down" - ANSWER "I feel like I have to push down"
(rationale: stage two is from complete dilation to delivery. Having to push down is often a
hallmark sign of this stage. Crowning, or feeling the baby coming out, occurs at the end of
stage two. Rupture of membranes and fetal movement are not related to phases and stages
of labor)
The nurse is providing care for a laboring client with a GTPAL of 65005 at term. Which
assessments will the nurse include in this client's plan of care for after delivery? (select all
that apply.)
- fundal assessment should be made every 5 minutes for 30 minutes after delivery of the
placenta
- assess for lochia every 5 minutes for 30 minutes after delivery of the placenta
- place the infant to breast immediately after delivery
- encourage the mother to talk to her newborn
3
ANSWERS|LATEST!!!!2025/2026|GUARANTEED
The nurse is reviewing fetal circulation with a nursing student. The nurse concludes the
student understands the teaching when which statements are made? (select all that apply)
- the umbilical cord contains two veins and one artery
- umbilical artery blood has the highest oxygenation
- fetal oxygenation occurs through the placenta
- the foramen ovale is open in the fetal state
- blood flows from the placenta to the fetal heart - ANSWER - fetal oxygenation occurs
through the placenta
- the foramen ovale is open in the fetal state
- blood flows from the placenta to the fetal heart
The laboring client at term states to the nurse, "i think my water just broke." the nurse
observes a shiny, gelatinous, rope-like structure protruding from the client's vaginal area.
What is the next nursing action?
- call for help
- place the client in knee chest position
- increase the mainline IV fluids
- reassure the client - ANSWER place the client in knee chest position
(rationale: this client is showing signs of an obstetric emergency of a prolapsed umbilical
cord. Compression of the cord can lead to fetal anoxia. Placing the client in knee-chest
position reduces the weight of the presenting part off of the cord. The nurse will need to
complete the remaining options, but oxygenation of the fetus takes priority)
1
,A client at 39 weeks gestation overhears her health care provider say to the nurse, "her
bishop score is 10." the client asks the nurse, "what does that mean?" what is the nurse's
best response?
- "your baby is in a good position to deliver."
- "your cervix is ready for labor."
- "labor will start in the next 24 hours."
- "your amniotic sac will rupture soon." - ANSWER "your cervix is ready for labor."
(rationale: the bishop score is a representation of cervical consistency, dilation, position, and
effacement, and of station of the presenting part. The lowest score is 0, indicating the cervix
is not ready to open. The highest score is 13. While the score includes the placement of the
presenting part in relationship to the ischial spines, it is not reflective of fetal positioning. It
is nonpredictive of onset of labor or rupture of membranes)
A mother who is breastfeeding her baby receives instructions from the nurse. Which
instructions are most effective in preventing nipple soreness? (select all that apply.)
- massage a small amount of medical grade lanolin into the nipple
- increase nursing time gradually over several days
- ensure that the baby is positioned correctly for latching on
- manually express a small amount of milk before nursing
- wear a cotton bra with nonbinding support - ANSWER - massage a small amount of
medical grade lanolin into the nipple
- ensure that the baby is positioned correctly for latching on
A client at 36 weeks gestation presents to labor and delivery and states to the nurse, "i have
been leaking fluid for about 2 days now. At first I thought it was urine. Now, I am not so
sure." which nursing actions are most appropriate for this client? (select all that apply.)
- assess maternal vital signs
- place an electronic fetal monitor
- place a peri pad
- assess the fluid for a foul odor
2
, - obtain a maternal blood glucose
- obtain a complete blood count - ANSWER - assess maternal vital signs
- place an electronic fetal monitor
- assess the fluid for a foul odor
- obtain a complete blood count
(rationale: until rupture of membranes has been ruled out, the nurse must provide care as if
they are ruptured. Since it has been 2 days with leaking fluid, the client may have developed
chorioamnionitis)
The nurse is providing care to a laboring client at term. Which client statement indicates to
the nurse that the client is entering stage two of labor?
- "I feel the baby coming out NOW!"
- "I feel like my water just broke"
- "I feel my baby moving around a lot"
- "I feel like I have to push down" - ANSWER "I feel like I have to push down"
(rationale: stage two is from complete dilation to delivery. Having to push down is often a
hallmark sign of this stage. Crowning, or feeling the baby coming out, occurs at the end of
stage two. Rupture of membranes and fetal movement are not related to phases and stages
of labor)
The nurse is providing care for a laboring client with a GTPAL of 65005 at term. Which
assessments will the nurse include in this client's plan of care for after delivery? (select all
that apply.)
- fundal assessment should be made every 5 minutes for 30 minutes after delivery of the
placenta
- assess for lochia every 5 minutes for 30 minutes after delivery of the placenta
- place the infant to breast immediately after delivery
- encourage the mother to talk to her newborn
3
