A nurse in a labor unit is admitting a patient who reports experiencing painful contractions. The nurse determines that the contractions last for 1 minute and occur every 3 minutes.The nurse records the following vital signs: fetal heart rate of 130/min, maternal heart rate of 128/min, and maternal blood pressure of 92/54 mm Hg. What should the nurse prioritize doing next?

Notify the provider of the findings.

Ask the patient if she needs pain medication.

Have the patient void.

Position the patient with one hip elevated.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Given the frequency and duration of the contractions, along with the maternal and fetal vital signs, it is important to notify the healthcare provider immediately. These could be signs of labor progression and the healthcare provider can provide further instructions based on the clinical situation.
Choice B rationale
While managing pain is important, the priority in this situation is to communicate with the healthcare provider due to the frequency of contractions and the vital signs.
Choice C rationale

Having the patient void is not the priority in this situation. While a full bladder can affect labor progression, the frequency of contractions and the vital signs take precedence.
Choice D rationale
Positioning the patient with one hip elevated is not the priority in this situation. This position is often used to alleviate supine hypotensive syndrome, but the patient’s blood pressure is not indicating this condition.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Elevating the client’s legs is not the first action to take. While it can help with circulation, it does not directly address the issue of late decelerations.
Choice B rationale
Administering oxygen using a nonrebreather mask can be beneficial as it can increase the amount of oxygen available to the fetus. However, it is not the first action to take.
Choice C rationale
Placing the client in the lateral position is the correct action. This position can help improve placental blood flow and potentially improve the oxygen supply to the fetus.
Choice D rationale
Increasing the rate of maintenance IV infusion is not the first action to take. While it can help maintain hydration and blood pressure, it does not directly address the issue of late decelerations.

A. Fetal hyperinsulinemia. B. Preterm delivery. C. Perinatal asphyxia. D. Placental inefficiency.

Correct Answer is D

Explanation

Choice A rationale
Fetal hyperinsulinemia is a condition where the fetus produces an excess amount of insulin, and it is more commonly associated with macrosomia (large for gestational age) rather than being small for gestational age.
Choice B rationale

Preterm delivery can result in a baby being small for birth weight, but it does not cause a baby to be small for gestational age. Small for gestational age means the baby’s weight is less than the 10th percentile for their gestational age.
Choice C rationale
Perinatal asphyxia, a lack of oxygen before, during, or just after birth, does not cause a baby to be small for gestational age. It can cause other complications, such as organ damage.
Choice D rationale
Placental inefficiency, where the placenta does not work as well as it should, can cause a baby to be small for gestational age. This is because the baby may not receive enough oxygen and nutrients from the mother.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is educating the mother of a newborn who was born small for gestational age. Which of the following should the nurse mention as a potential cause of this condition?

Correct Answer is D

Explanation

A nurse is caring for a client who is 42 weeks of gestation. Exhibits Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse’s planned actions are anticipated, nonessential, or contraindicated.

Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take. Exhibits here Exhibits Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take.

Select the 4 assessment findings the nurse should report to the provider. Exhibits A nurse in an antepartum clinic is caring for a client who is pregnant. Exhibits:

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

What action should a nurse take when caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad, with the fundus midline and firm at the umbilicus?

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down”, sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

A nurse is preparing to administer magnesium sulfate IV to a client who is in labor. Which of the following is the primary nursing assessment for this client?