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1. A pregnant woman at 38 weeks of gestation is admitted to the labor and
delivery unit with regular contractions. The nurse performs a vaginal
examination and finds that the cervix is 4 cm dilated, 80?faced, and the
fetal head is at -1 station. What is the appropriate nursing action?
A) Prepare the woman for delivery
B) Administer oxytocin as ordered
C) Monitor the fetal heart rate and uterine activity
D) Encourage the woman to ambulate or change positions
Answer: C) Monitor the fetal heart rate and uterine activity
Rationale: The woman is in active labor and needs to be monitored for signs of
fetal well-being and progress of labor. Preparing for delivery, administering
oxytocin, or encouraging ambulation are not indicated at this stage.
2. A nurse is caring for a newborn who was delivered by vacuum extraction.
The nurse observes a large, boggy swelling on the scalp that crosses the
suture lines. What is the most likely diagnosis?
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