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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Cannabis withdrawal typically presents with symptoms such as irritability, anxiety, insomnia, decreased appetite, and physical discomfort, but not constricted pupils, delayed reflexes, and decreased blood pressure.

B. Opioid intoxication can cause constricted pupils (miosis), delayed reflexes, and decreased blood pressure, among other symptoms such as respiratory depression, drowsiness, and altered mental status.

C. Amphetamine intoxication typically presents with symptoms such as dilated pupils, increased blood pressure, tachycardia, agitation, and hallucinations, but not constricted pupils, delayed reflexes, and decreased blood pressure.

D. Alcohol withdrawal typically presents with symptoms such as tremors, anxiety, agitation, hallucinations, increased heart rate and blood pressure, but not constricted pupils, delayed reflexes, and decreased blood pressure.

A. "Try to suppress your grief when your child is present." B. "Avoid discussing the funeral when your child is around." C. "Bring the child to the funeral service before visitors arrive." D. "School-age children tend to view death as a temporary form of sleep."

Correct Answer is C

Explanation

A. Encouraging the parents to suppress their grief can be detrimental to their emotional well- being and may inhibit healthy grieving processes.
B. Avoiding discussing the funeral when the child is around may create confusion and anxiety for the child, who may sense that something significant is happening but is excluded from the discussion.
C. Including the child in the funeral service before visitors arrive allows the child to be part of the grieving process and provides an opportunity for closure and understanding of the sibling's death in a supportive environment.
D. While it is important for parents to understand how school-age children perceive death, this statement does not offer guidance on how to support the child during the grieving process.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following?

Correct Answer is B

Explanation

A nurse is providing grief counseling for the parents of a school-age child whose sibling recently died. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include?

A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture?

A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?

A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following Instructions should the nurse include?

A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications?

A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect?

A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect?