A nurse is caring for a client in the second stage of labor.

The nurse observes retraction of the fetal head against the maternal perineum after the fetal head is birthed.

What potential condition could the client be experiencing, what parameters should the nurse monitor to assess the client’s progress, and what actions should the nurse take?

Answer and Explanation

The Correct Answer is ["-"]

The nurse is observing a potential case of shoulder dystocia, a condition where the baby’s head has been delivered but one of the shoulders becomes stuck behind the mother’s pelvic bone. The nurse should monitor the mother’s vital signs and the baby’s heart rate. The nurse should call for immediate assistance, perform maneuvers to help deliver the baby, and prepare for a potential emergency cesarean section if necessary.

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Correct Answer is B

Explanation

Choice A rationale
Missing a menstrual cycle and reporting vaginal spotting could indicate early pregnancy or other non-emergency conditions. While this client should be evaluated, it is not the highest priority.
Choice B rationale
A client at 28 weeks of gestation reporting painless vaginal bleeding could be experiencing placenta previa or placental abruption, both of which are obstetric emergencies. This client should be prioritized for immediate evaluation.
Choice C rationale
A client at 38 weeks of gestation reporting symptoms of a cough and fever may have an upper respiratory infection. While this should be evaluated, it is not the highest priority unless the client is in distress.
Choice D rationale
Nausea and vomiting are common in early pregnancy. A client at 14 weeks of gestation reporting these symptoms would need evaluation, but it is not the highest priority.

A. Baseline BP 140/85, current BP 129/80 B. Baseline BP 110/70, current BP 145/85 C. Baseline BP 120/80, current BP 126/85 D. Baseline BP 110/60, current BP 120/63 .

Correct Answer is B

Explanation

Choice A rationale
A baseline BP of 140/85 mmHg is considered high, but a current BP of 129/80 mmHg is within the normal range. Therefore, this would not typically indicate a risk for pregnancy-induced hypertension.
Choice B rationale
A significant increase in blood pressure from a baseline of 110/70 mmHg to a current BP of 145/85 mmHg could indicate a risk for pregnancy-induced hypertension.
Choice C rationale
A slight increase in blood pressure from a baseline of 120/80 mmHg to a current BP of 126/85 mmHg would not typically indicate a risk for pregnancy-induced hypertension.
Choice D rationale
An increase in blood pressure from a baseline of 110/60 mmHg to a current BP of 120/63 mmHg would not typically indicate a risk for pregnancy-induced hypertension.

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Naxlex Comprehensive Predictor Exams

As a nurse in an antepartum unit performing triage, which client should be prioritized?

Correct Answer is B

Explanation

Which blood pressure (BP) finding during the second trimester indicates a risk for pregnancy-induced hypertension?

Correct Answer is B

Explanation

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

A nurse is monitoring a patient who is receiving magnesium sulfate to manage pre-eclampsia. Which of the following observations should the nurse report to the healthcare provider?

A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage?

A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Which condition is the client most likely experiencing?

A nurse is caring for a client in the first stage of labor who is undergoing external fetal monitoring and receiving IV fluids. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is the correct interpretation of this finding

A nurse is caring for a group of patients on an intrapartum unit. Which of the following findings should be reported to the healthcare provider immediately?

A client is due to receive a subcutaneous injection of enoxaparin, 30 mg. How many mL should the nurse administer if the answer is to be rounded to the nearest tenth? (Use a leading zero if applicable.