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.

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Correct Answer is ["B","E"]

Explanation

Choice A: Amniocentesis is not primarily performed to determine the gender of the fetus. The main indication for this procedure is to detect genetic abnormalities or chromosomal disorders.
Choice B: The primary purpose of an amniocentesis is to detect chromosomal abnormalities such as Down syndrome (trisomy 21), trisomy 18, and trisomy 13, among others.
Choice C: Rh incompatibility is assessed through blood tests, not amniocentesis. It involves determining the Rh factor of the mother's blood and monitoring for potential Rh sensitization.

Choice D: Cephalopelvic disproportion refers to a situation where the baby's head is too large or the mother's pelvis is too small to allow for a vaginal delivery. It is not related to amniocentesis.
Choice E: While detecting neural tube defects can be done through amniocentesis, it is not the primary indication for the procedure. Neural tube defects can also be screened for through blood tests and ultrasound examinations. Amniocentesis is more commonly used for chromosomal analysis.

A. Variable decelerations are a result of the administration of IV narcotic analgesics. B. Variable decelerations are related to fetal head compression. C. Variable decelerations are due to umbilical cord compression. D. Variable decelerations are caused by uteroplacental insufficiency.

Correct Answer is C

Explanation

A) Variable decelerations are a result of the administration of IV narcotic analgesics: IV narcotic analgesics can cause changes in the fetal heart rate, but they are more commonly associated with early decelerations, not variable decelerations.

B) Variable decelerations are related to fetal head compression: Fetal head compression is associated with early decelerations, not variable decelerations.
C) Variable decelerations are due to umbilical cord compression: This is the correct answer.

Variable decelerations occur due to compression of the umbilical cord during contractions, leading to transient decreases in fetal blood flow and oxygenation.
D) Variable decelerations are caused by uteroplacental insufficiency: Uteroplacental insufficiency is associated with late decelerations, not variable decelerations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is at 18 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

Correct Answer is C

Explanation

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?