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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Correct Answer is C

Explanation

A. Decreased serum osmolarity: Fluid volume deficit typically leads to an increase in serum osmolarity due to concentration of solutes in the blood, not a decrease.

B. Decreased hematocrit: Dehydration causes hemoconcentration, leading to an increase in hematocrit, not a decrease.

C. Elevated blood urea nitrogen (BUN): Dehydration results in decreased renal perfusion and concentration of urea in the blood, leading to elevated BUN levels.

D. Lower urine specific gravity: Dehydration causes increased urine concentration, resulting in higher urine specific gravity, not lower.

A. "You looked like you would be the most likely to talk back with me." B. "Let's go see what activities are going on outside." C. "Why shouldn't I talk to you? You looked lonely." D. "You're curious why I am interested in you and not the others?"

Correct Answer is D

Explanation

A. This response does not address the adolescent's underlying question and may come across as dismissive.

B. This response avoids addressing the adolescent's question and suggests changing the subject.

C. This response is somewhat confrontational and does not explore the adolescent's feelings or concerns.

D. This response acknowledges the adolescent's curiosity and opens the door for further discussion about why the nurse chose to engage with them. It invites the adolescent to explore their feelings and thoughts.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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,

A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

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?

A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take?

A nurse is teaching a client who is scheduled for placement of a peripherally inserted central catheter (PICC) line. Which of the following Information should the nurse include in theteaching?

A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is:

A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?