A nurse is caring for a client who is nulliparous and in the first stage of labor. The last
internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?

Perform another internal exam.

Notify the client's provider.

Check the FHR.

Obtain a pH test of the fluid.

Answer and Explanation

The Correct Answer is C

A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.

B. Notifying the client's provider may be necessary, but it is not the immediate priority.

C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.

D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Profuse milky white discharge: Bacterial vaginosis is characterized by a fishy odor and a thin, homogeneous, grayish-white discharge, not milky white. However, this option is the most closely associated with bacterial vaginosis among the choices provided.

B. Frequency and dysuria: These symptoms are more indicative of urinary tract infection rather than bacterial vaginosis.

C. Low-grade fever: Fever is not typically associated with bacterial vaginosis unless there is a secondary infection present.

D. Hematuria: Hematuria, or blood in the urine, is not a typical symptom of bacterial vaginosis.

A. Wall suction set to 60 mm Hg B. Drainage fluid is greenish-yellow C. Aspirate pH of 3 D. Abdominal rigidity

Correct Answer is B

Explanation

A. The wall suction setting does not directly indicate the functioning of the NG tube.

B. Greenish-yellow drainage fluid may indicate the presence of bile in the stomach, suggesting

that the NG tube is not adequately draining gastric contents, which could indicate a malfunction.

C. An aspirate pH of 3 indicates gastric acidity, which is expected in the stomach and does not necessarily indicate a problem with NG tube function.

D. Abdominal rigidity may suggest intra-abdominal pathology but does not specifically indicate NG tube dysfunction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly?

Correct Answer is B

Explanation

A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings?

A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting. Which of the following Instructions should the nurse include?

A nurse is planning care for a child who has increased intracranial pressure with a decrease in the level of consciousness. Which of the following interventions should the nurse include inthe plan of care?

A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states,

The nurse continues to care for the client in the intensive care unit. Exhibits Complete the following sentence by using the lists of options. The nurse should first administer the client's dropdownto the client's dropdown.

A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?