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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Brushing teeth immediately after eating may exacerbate nausea in some individuals. It is recommended to wait a while after eating before brushing teeth, or rinse the mouth with water.

B. Lying down after meals can worsen symptoms of nausea and reflux. Remaining upright or sitting up after meals may help alleviate symptoms.

C. Drinking large amounts of water with meals may exacerbate feelings of fullness and contribute to nausea. Sipping small amounts of fluids between meals is recommended.

D. Eating a dry carbohydrate, such as crackers or toast, before getting out of bed can help alleviate morning sickness by stabilizing blood sugar levels and absorbing stomach acid.

A. Add the contents of the capsules to food. B. Dissolve the capsules in a glass of chocolate milk. C. Administer the medication with a glass of orange juice. D. Administer the medication at bedtime.

Correct Answer is C

Explanation

A. Mixing ferrous sulfate capsules with food may alter the absorption of the medication. It is generally recommended to take iron supplements on an empty stomach for better absorption, unless gastrointestinal side effects occur, in which case taking it with food can help reduce

irritation.

B. Dissolving ferrous sulfate capsules in chocolate milk or any other liquid may affect the taste and consistency of the drink. Additionally, chocolate milk may contain substances that could

interfere with iron absorption.

C. Administering iron supplements with a glass of orange juice is a common recommendation because vitamin C enhances the absorption of iron. This combination helps improve the bioavailability of the iron supplement.

D. There is no specific indication to administer ferrous sulfate capsules at bedtime. It is typically recommended to take iron supplements on an empty stomach for better absorption, unless gastrointestinal side effects occur, in which case taking it with food can help reduce irritation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel?

At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication?

A nurse manager is reviewing documentation standards with a group of newly licensed nurses. Which of the following statements should the nurse manager include in the teaching?

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 teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following Instructions should the nurse include?

A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic?

A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of the following medications should the nurse expect the provider to prescribe?