A nurse in the labor unit is admitting a patient who reports experiencing painful contractions.
The nurse determines that the contractions last 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 is the nurse’s priority action?

Have the patient void.

Ask the patient if she needs pain medication.

Turn the patient on her side and recheck the blood pressure.

Notify the healthcare provider of the findings.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.

Choice B rationale

Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.

Choice C rationale

Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.

Choice D rationale

Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.

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Correct Answer is A

Explanation

Choice A rationale

The rubella vaccine is a live vaccine, which means it contains a weakened version of the virus. Because the virus is still active, live vaccines are not safe for pregnant people. There is a small chance they may pass the virus to the baby. Therefore, it is recommended that adults of childbearing age should avoid getting pregnant for at least four weeks after receiving the MMR vaccine. This is to ensure the safety of both the mother and the baby.

Choice B rationale

This statement is incorrect. The rubella vaccine does not require additional shots after each baby with Rh-positive blood. The rubella vaccine is typically administered in childhood and provides long-term protection.

Choice C rationale

This statement is also incorrect. The rubella vaccine does not require additional shots in 1 month and again in 6 months. The vaccine provides long-term protection and does not typically require frequent boosters.

Choice D rationale

While it’s true that some vaccines can cause side effects such as fever and vomiting, these are not common side effects of the rubella vaccine. Therefore, this statement is not entirely accurate.

A. A client diagnosed with preeclampsia reports epigastric pain and unresolved headache B. A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions C. A client diagnosed with preeclampsia has 2+ proteinuria and 2+ patellar reflexes D. A client at 28 weeks of gestation receiving terbutaline reports fine tremors

Correct Answer is A

Explanation

Choice A rationale

A client diagnosed with preeclampsia reporting epigastric pain and unresolved headache is a serious concern. Epigastric pain could indicate severe liver involvement, and a persistent headache could be a sign of progressing neurological involvement, both of which are severe features of preeclampsia. These symptoms suggest the condition may be worsening to eclampsia, a life-threatening complication characterized by the onset of seizure activity or coma in a woman with preeclampsia. Immediate medical attention is necessary to prevent further complications.

Choice B rationale

A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing preterm labor. However, emotional distress and contractions do not necessarily indicate a medical emergency. It’s important to monitor the situation, but it does not need to be immediately reported to the provider.

Choice C rationale

A client diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes are expected findings. Proteinuria is a common sign of preeclampsia, and hyperreflexia can occur due to increased neuromuscular irritability. While these should be monitored, they do not need to be immediately reported to the provider.

Choice D rationale

A client at 28 weeks of gestation receiving terbutaline reporting fine tremors is an expected side effect of the medication. Terbutaline, a beta-adrenergic agonist, can cause tremors by stimulating the nervous system. While it may be uncomfortable for the client, it is not a medical emergency.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client’s prenatal laboratory findings reveal no immunity to rubella.The health care provider orders the rubella vaccine.The nurse concludes that teaching about this medication is effective when the client states which of the following?

Correct Answer is A

Explanation

As a nurse caring for a group of clients on an intrapartum unit, which of the following findings should be immediately reported to the provider?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused.Which of the following actions should the nurse take to address the client’s safety needs?

A nurse is educating a group of pregnant women about neural tube defects.Which of the following conditions should the nurse mention as an example of a neural tube defect?

A nurse manager is conducting an in-service program about delegation to assistive personnel (AP) with staff nurses on the unit.Which statement by a staff nurse indicates that the teaching was effective?

A nurse is caring for a patient who is about to undergo a biophysical profile.The patient asks the nurse what will be evaluated during this test.Which of the following should the nurse include? (Select all that apply.)

A nurse is caring for a client who is on warfarin therapy for atrial fibrillation.The client’s INR is 5.2. Which of the following medications should the nurse prepare to administer?

A nurse is caring for a client diagnosed with gastrointestinal bleeding.Which of the following actions should the nurse take first?

Exhibits Based on the information in the newborn's medical record, the nurse determines that the newborn is at risk for developing which of the following complications?

A nurse is reviewing the medical record of a client who has moderate Alzheimer's disease. Exhibits To effectively manage the provider prescriptions, which of the following tasks should the nurse assign to an assistive personnel (AP)?