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. Weakened uterine contractions B. Maternal blood glucose of 63 mg/dL C. Decreased fetal heart rate D. Enhanced production of fetal lung surfactant

Correct Answer is D

Explanation

Choice A rationale

Betamethasone, a corticosteroid, is not known to weaken uterine contractions. It is often administered to pregnant women at risk of preterm delivery to enhance fetal lung maturation and reduce complications associated with prematurity.

Choice B rationale

Betamethasone can potentially increase blood glucose levels, not decrease them. This is particularly relevant in women with gestational diabetes, as corticosteroids can exacerbate hyperglycemia.

Choice C rationale

Betamethasone does not typically decrease the fetal heart rate. Instead, it is used to help mature the lungs of the fetus.

Choice D rationale

Betamethasone is administered to pregnant women at risk of preterm delivery to enhance the production of surfactant in the fetal lungs. Surfactant is a substance that prevents the small air sacs in the lungs from collapsing, thereby aiding in the baby’s ability to breathe after birth.

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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

A nurse is providing care for a patient who is 28 weeks pregnant and has received betamethasone.The nurse recognizes that the use of betamethasone affects which of the following?

Correct Answer is D

Explanation

A nurse is preparing to discharge a patient who has sickle cell anemia following an acute crisis episode.Which instructions should the nurse include in the teaching?

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?

A pregnant couple at 14 weeks gestation has just been told that they both are carriers of an autosomal-recessive disorder.The nurse who is providing genetic counseling should take which of the following actions?

A nurse is administering Packed Red Blood Cells (PRBC) to a client who reports having lower back pain and feeling chilled and itchy.Which of the following actions should the nurse take first?

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?

The nurse is educating a female client about the onset of menopause and the resulting atrophy of the vulvar organs.The nurse should recognize that the major cause for these symptoms is related to which of the following?

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)?