A nurse on a labor unit is admitting a client who is lying supine in her bed and reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min,
maternal heart rate 128/min, and maternal blood pressure 82/54 mm Hg. Which of the following is the first priority action for the nurse to take?

Reposition the client with one hip elevated or on her left side.

Notify the provider of the findings.

Ask the client if she needs pain medication.

Have the client empty her bladder.

Answer and Explanation

The Correct Answer is A

A) Reposition the client with one hip elevated or on her left side: This is the correct first priority action. The client's vital signs indicate hypotension (low blood pressure), which may be caused by supine hypotensive syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood return to the heart and causing a drop in blood pressure. Repositioning the client on her left side or elevating one hip can relieve the pressure on the vena cava and
improve blood flow to both the mother and the baby.

B)   Notify the provider of the findings: While it is essential to inform the provider about the client's status, the first priority is to address the potential cause of hypotension and maternal discomfort.

C)   Ask the client if she needs pain medication: Pain management is essential, but the client's vital signs and potential hypotensive condition take precedence as the first priority.
D)   Have the client empty her bladder: Emptying the bladder can help reduce pressure on the vena cava and may improve blood flow, but it is not the first priority action in this situation. Repositioning the client is the initial priority to relieve supine hypotensive syndrome.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Retained bile in the liver results in delayed digestion: This statement is not related to the cause of heartburn.
B) Increased estrogen production causes increased secretion of hydrochloric acid: While hormonal changes during pregnancy can contribute to heartburn, it is specifically increased progesterone that leads to relaxation of the cardiac sphincter and delayed gastric emptying, which are more directly linked to heartburn.
C) Pressure from the growing uterus displaces the stomach: Uterine pressure on the stomach can lead to a feeling of fullness, but it is not the primary cause of heartburn during pregnancy.
D) Increased progesterone production causes relaxation of the smooth muscle relaxation of the cardiac sphincter and delayed gastric emptying: This is the correct answer. Increased progesterone levels during pregnancy relax the lower esophageal sphincter, leading to gastric acid reflux into the esophagus and causing heartburn.

A. "This will determine if there is more than one fetus." B. "It assists in identifying the location of the placenta and fetus." C. "This is a screening tool for spina bifida." D. "It is useful for estimating fetal age."

Correct Answer is B

Explanation

Choice A: An ultrasound can indeed determine the number of fetuses if a client is carrying multiples, but this is not the primary reason for performing an ultrasound before amniocentesis.

Choice B: An ultrasound is typically done before an amniocentesis to visualize the location of the placenta and fetus. This information is important to ensure that the amniocentesis needle is safely inserted away from the placenta and the fetus.

Choice C: The primary purpose of an amniocentesis is to obtain a sample of amniotic fluid to screen for genetic conditions, not specifically for spina bifida.

Choice D: Fetal age can be estimated through an ultrasound, but this is not the primary reason for performing an ultrasound before an amniocentesis. The main goal of the procedure is to obtain a sample of amniotic fluid for genetic testing.

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 in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

A nurse is caring for a client who is scheduled for a maternal serum alphafetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client?

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg, and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?

A nurse in a family planning clinic is caring for a 17 year old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

A nurse in a prenatal clinic is caring for a client who states that she might be pregnant because she feels the baby moving. How does the nurse classify this statement by the client?