A first-time pregnant woman at 36 weeks of gestation is admitted to the labor and delivery unit because her membranes ruptured 30 minutes ago.

The initial assessment indicates a 2 cm cervical dilation, 50% effacement, -2 station, vertex presentation, greenish- colored amniotic fluid, and contractions occurring every 3 to 5 minutes.

There is a decrease in fetal heart rate after the last four contraction peaks.

What should the nurse do first?

Administer oxygen via a face mask.

Apply an internal fetal heart monitor.

Use a vibroacoustic stimulator.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Administering oxygen via a face mask is the first intervention the nurse should do. This is because the decrease in fetal heart rate after the last four contractions indicates possible fetal distress, which can be caused by insufficient oxygen. Administering oxygen to the mother can increase the amount of oxygen available to the fetus, potentially alleviating the distress.
Choice B rationale
Applying an internal fetal heart monitor can provide more accurate and continuous data about the fetal heart rate and contractions. However, this is usually not the first intervention because it is invasive and can only be done if the cervix is sufficiently dilated and the membranes have ruptured.
Choice C rationale
Using a vibroacoustic stimulator is a method used to wake a sleeping baby in the womb during a non-stress test. It is not typically used in response to signs of fetal distress during labor.

Choice D rationale
Notifying the healthcare provider is important when there are signs of fetal distress. However, the nurse has interventions, such as administering oxygen, that they can and should do immediately while the healthcare provider is being notified.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Monitoring the client’s white blood cell count is important in this case. An elevated white blood cell count is a common sign of infection, and regular monitoring can help assess the client’s response to treatment.
Choice B rationale
Implementing contact precautions for staff and visitors is crucial when caring for a client with a potential VRE infection. VRE is a multi-drug resistant organism that can be spread through direct contact, so strict infection control measures are necessary.
Choice C rationale
Using standard precautions and wearing a mask is generally good practice in healthcare settings to prevent the spread of infections. However, a mask is not specifically required for contact precautions with VRE456.
Choice D rationale
Explaining the purpose of a low bacteria diet is not relevant in this case. While diet can play a role in overall health and recovery, it is not a specific intervention for a client with a potential VRE infection.
Choice E rationale
Sending wound drainage for culture and sensitivity is an important step in confirming the presence of VRE and determining the most effective antibiotic therapy.

A. Use a cushion when sitting. B. Offer a high protein diet. C. Provide only distilled water. D. Document abdominal girth.

Correct Answer is D

Explanation

Choice A rationale
Using a cushion when sitting can provide comfort but does not directly address the client’s electrolyte imbalance, elevated blood pressure, or weight gain.

Choice B rationale
Offering a high protein diet can be beneficial for clients with hepatic failure to support liver regeneration and prevent malnutrition. However, it does not directly address the client’s immediate issues.

Choice C rationale

Providing only distilled water does not address the client’s electrolyte imbalance, elevated blood pressure, or weight gain. In fact, it could potentially exacerbate electrolyte imbalances.

Choice D rationale
Documenting abdominal girth can help monitor for fluid accumulation (ascites), a common complication of hepatic failure that can contribute to weight gain and elevated blood pressure.

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Naxlex Comprehensive Predictor Exams

A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

The nurse identifies an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours in a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Correct Answer is D

Explanation

What is the most crucial nursing intervention to include in the care plan for a patient who is 12 hours post- thyroidectomy?

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