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 B

Explanation

A. 3hr oral glucose tolerance test - This test is typically used for diagnosing gestational diabetes or impaired glucose tolerance, not for long-term management.

B. HbA1c - Hemoglobin A1c reflects the average blood glucose levels over the past 2-3 months and is a reliable indicator of long-term glycemic control.

C. Fasting blood glucose test - This provides a snapshot of blood glucose levels at a specific point in time and is not as reliable for assessing long-term glycemic control as HbA1c.

D. Urinalysis for ketones - Urinalysis for ketones is useful for detecting acute complications such as diabetic ketoacidosis but does not reflect long-term management of blood glucose levels.

A. Insist the client use direct eye contact during the interview. B. Seat the client at least 3.7 m (12 feet) from the nurse. C. Position the client's chair between the nurse's chair and the door. D. Lean in slightly when speaking to the client.

Correct Answer is D

Explanation

A. Insisting on direct eye contact may be uncomfortable or distressing for some clients, particularly those with certain mental health conditions or cultural backgrounds. It's important to respect the client's comfort level.

B. Seating the client too far away can create a sense of distance and may hinder effective communication. A closer seating arrangement facilitates rapport and engagement.

C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially if they have concerns about their safety or autonomy.

D. Leaning in slightly when speaking to the client demonstrates attentiveness and engagement. It can also convey a sense of confidentiality and respect for the client's space.

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Naxlex Comprehensive Predictor Exams

A home health nurse is reviewing treatment goals with a client who has diabetes mellitus.The nurse should evaluate which of the following laboratory tests to determine effective long- term management of blood glucose levels?

Correct Answer is B

Explanation

A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview?

Correct Answer is D

Explanation

An occupational health nurse at a group of health care clinics is planning activities to prevent and control the spread of communicable disease. The nurse should identify that which of the following activities is a secondary level of prevention?

A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). For which of the following findings should the nurse monitor as a potential complication of TPN?

A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following findings requires immediate intervention by the nurse?

A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage?

A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

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?

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?