A nurse on a labor unit is admitting a client who 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 92/54 mm Hg. Which of the following is the priority action for the nurse to take?

Have the client void.

Position the client with one hip elevated.

Ask the client if she needs pain medication.

Notify the provider of the findings.

Answer and Explanation

The Correct Answer is B

The correct answer is B. Position the client with one hip elevated.

A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.

B. Positioning the client with one hip elevated is the priority action.

The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.

C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.

D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A Reason:

"I should have a goal of maintaining my fasting blood glucose between 100 and 120." This statement does not indicate understanding of the teaching. Recommended target for fasting blood glucose levels during pregnancy in women with diabetes is typically lower, often between 60 and 90 mg/dL.

Choice B Reason:

"I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." This statement does not indicate understanding of the teaching . Exercising when blood glucose is already elevated to 250 or greater may not be safe. Exercise is generally recommended to help manage blood glucose levels, but the specific approach and timing should be discussed with the healthcare provider.

Choice C Reason:

"I will continue taking my insulin if I experience nausea and vomiting." This statement reflects an awareness of the importance of continuing insulin administration even if the client is experiencing nausea and vomiting. Consistent insulin management is crucial for maintaining blood glucose levels within the target range during pregnancy.

Choice D Reason:

"I will ensure that my bedtime snack is high in refined sugar." This statement does not indicate understanding of the teaching. Bedtime snacks should focus on providing sustained energy and stabilizing blood glucose levels. A snack high in refined sugar is not recommended as it can lead to fluctuations in blood glucose levels.

A. Determine respiratory function. B. Increase the TV fluid rate. C. Access emergency medications from cart D. Collect a maternal blood sample for coagulopathy studies

Correct Answer is A

Explanation

The correct answer is A.

A. Determine respiratory function: The priority is to assess the client's airway, breathing, and circulation (ABCs). If the client becomes unresponsive, the nurse should quickly assess whether the airway is clear, check for breathing, and determine if there is a pulse. This initial assessment is crucial for identifying and addressing any immediate life-threatening issues.

B. Increase the TV fluid rate: While fluid administration may be necessary in certain situations, it is not the first priority when a client becomes unresponsive. Assessing respiratory function and circulation takes precedence to address immediate life-threatening concerns.

C. Access emergency medications from the cart: Accessing emergency medications may be necessary, but it should occur after the initial assessment of the client's airway, breathing, and circulation. Administering medications without first assessing the client's ABCs may delay appropriate interventions.

D. Collect a maternal blood sample for coagulopathy studies: This action is important for assessing coagulation status, but it is not the first priority when a client becomes unresponsive. The immediate focus should be on ensuring the client has a patent airway, is breathing, and has a pulse.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsi

A nurse is calculating a client's expected date of birth using Nägele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagin

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching?

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as -1. Which of the following interpretations of this finding should the nurse make?