A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?

Incompetent cervix.

Postpartum hemorrhage.

Ectopic pregnancy.

Hyperemesis gravidarum.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
The incompetent cervix is not related to the client's current situation. An incompetent cervix refers to a weakened cervix that may result in premature dilation during pregnancy, leading to potential pregnancy loss or preterm birth. It is not relevant to the client's current stage of labour and cervical dilation.

Choice B rationale:
Postpartum haemorrhage is the correct condition to be concerned about in this situation. The client is 80% effaced and 8 cm dilated, which indicates she is in active labour. These signs of progress indicate that she is at risk for excessive bleeding after delivery, which is known as postpartum haemorrhage.

Choice C rationale:
An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, typically in the fallopian tube. This condition is not related to the client's current presentation, as she is already in active labour.

Choice D rationale:
Hyperemesis gravidarum is severe and persistent nausea and vomiting during pregnancy, usually during the first trimester. This condition is not relevant to the client's current situation, which involves active labour and cervical dilation.

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Correct Answer is D

Explanation

The correct answer is **d. The newborn is beginning to cough**.

Choice A rationale:

An irregular respiratory rate in a newborn is not necessarily an indication for nasopharyngeal suctioning. Irregular respirations can have various causes, and suctioning may not be the appropriate intervention.

Choice B rationale:

A respiratory rate of 32 breaths per minute is within the normal range for a newborn and does not indicate the need for nasopharyngeal suctioning.

Choice C rationale:

A pulse oximetry reading of 91% is low and may indicate the need for intervention, but it does not specifically indicate the need for nasopharyngeal suctioning. Other interventions, such as supplemental oxygen, may be more appropriate.

Choice D rationale:

The newborn beginning to cough is a clear indication that there may be secretions or obstruction in the nasopharynx, and suctioning may be necessary to clear the airway and improve respiratory function.

A. A client who is taking a thiazide diuretic. B. A client who is vomiting. C. A client who has salicylate intoxication. D. A client who has hypoventilation.

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Thiazide diuretics cause potassium and chloride loss, leading to metabolic alkalosis, not respiratory alkalosis. Hypokalemia decreases hydrogen ion excretion, increasing bicarbonate levels. Metabolic alkalosis is characterized by pH >7.45 and HCO₃⁻ >26 mEq/L rather than decreased PaCO₂.

Choice B rationale: Vomiting leads to metabolic alkalosis due to gastric acid loss. Hydrogen ion depletion increases bicarbonate concentration, shifting pH above normal. Arterial blood gases typically show increased HCO₃⁻ (>26 mEq/L) with a compensatory increase in PaCO₂ (>45 mmHg), not respiratory alkalosis.

Choice C rationale: Salicylate intoxication initially induces hyperventilation, reducing PaCO₂ levels below 35 mmHg and increasing pH above 7.45, leading to respiratory alkalosis. As toxicity progresses, metabolic acidosis may develop due to lactic acid accumulation, but early stages primarily present with respiratory alkalosis.

Choice D rationale: Hypoventilation leads to CO₂ retention, increasing PaCO₂ above 45 mmHg, forming carbonic acid (H₂CO₃) and causing respiratory acidosis. Blood gases show pH <7.35 with elevated PaCO₂, not respiratory alkalosis, which is caused by excessive CO₂ elimination through hyperventilation.

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A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?

Correct Answer is D

Explanation

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for respiratory alkalosis?

Correct Answer is C

Explanation

A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion?

A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor which of the following findings has an adverse effect.

A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings places the client at risk for postpartum haemorrhage?(Select all that apply.)

A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe.

A nurse is caring for a client who is experiencing uterine atony immediately following delivery. The client fails to respond to oxytocin administration. The nurse should anticipate the use of which of the following medications?