A 25-year-old female, with no prenatal care, is brought into your LAD unit by ambulance with vagina bleeding Based upon what she thinks in her LMP, she is suspected of being 26 weeks of gestation. The patients combative, yelling at staff, and refuses to change into a patient gown. The nurse suspects possible drug use and history of psychological disorders. She has had no prenatal care. What is not an appropriate nursing action at this time?

Ensure that the patient's external environment is free from excessive stimuli.

Ask her what drugs she has taken and when was the last time.

Administer prescribed sedatives.

Perform a vaginal exam.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Ensuring a calm environment by minimizing excessive stimuli is important for the safety and well-being of the patient.

B. Asking about drug use is essential to understand potential risks and provide appropriate care.

C. Administering sedatives to a combative patient without assessing the situation further could be dangerous. It could harm the patient and fetus, especially if drug use or psychological disorders are suspected.

D. Performing a vaginal exam is necessary to assess bleeding and determine if there are any signs of preterm labor or other complications.

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Correct Answer is C

Explanation

A. Amniotic fluid helps maintain a stable temperature for the fetus.

B. It cushions the fetus from external trauma.

C. Amniotic fluid does not protect from toxic substances, requiring clarification.

D. It enables the fetus to move, aiding musculoskeletal development.

A. Suction the baby as needed B. Teach mother how to do cord care C. Dry the baby D. Apply identification bracelets to mother and baby

Correct Answer is C, A, D, B

Explanation

Drying the baby is the most important first step to prevent heat loss and initiate thermoregulation. Suctioning is needed if there are signs of airway obstruction but is secondary to ensuring the baby’s warmth. Applying identification bracelets is necessary to ensure proper identification but is not as critical as ensuring the baby is warm and breathing. Teaching the mother cord care can be done after addressing more immediate concerns such as warmth and identification.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Amniotic fluid is important for maintaining fetal wellbeing. The nurse knows teaching needs to be reinforced when the nurse hears a woman making which statement to her husband?

Correct Answer is C

Explanation

Place the following actions that should be done for baby girl C immediately after birth from most important to least important. (ORDERED RESPONSE)

Correct Answer is C, A, D, B

Explanation

The doctor writes an order for Terbutaline to be given 5Q. Which assessment finding will cause the nurse to question this order?

The nurse is providing care for a woman with Type 1 Diabetes. Which of the following is true for the laboratory test for Glycosylated Hemoglobin A1C

The nurse is evaluating the effectiveness of breastfeeding of a neonate prior to discharge. Which of the following would be included in the LATCH score? (Select all that apply).

A patient is HIV+ and wants to know how this will affect her pregnancy and baby. What should be included in the response to this patient? (Select all that apply).

When caring for a laboring mother, late decelerations are noted on the fetal heart rate monitor. What actions should the nurse take? (Select all that apply

A postpartum woman telephones about her 6 day old infant. She is not scheduled for a weight check until the infant is 10 days old and she is worried about whether the baby is getting enough mi Which of the following statements demonstrate effective breastfeeding for her newborn?

A patient with pregnancy-induced hypertension is admitted complaining of pounding headache and epigastric pain. Nursing care is based on the knowledge that these signs indicate: