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.

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Correct Answer is C

Explanation

Choice A Reason:

Hemoglobin (Hgb) of 20 g/dL is elevated, but this can be a normal finding in a newborn and does not necessarily require immediate intervention.

Choice B Reason:

Total bilirubin of 5 mg/dL is within the normal range for a 24-hour-old newborn.

Choice C Reason:

Blood glucose 30 mg/dL. A blood glucose level of 30 mg/dL is significantly lower than the normal range for a newborn. Hypoglycemia in a newborn can lead to neurologic complications, so it is important to report this result promptly for further evaluation and intervention.

Choice D Reason:

White blood cell (WBC) count of 20,000/mm³ is within the expected range for a newborn and is not a cause for immediate concern. Newborns often have higher WBC counts shortly after birth.

A. Emotional lability B. Focusing phase C. Cognitive restructuring D. Couvade syndrome

Correct Answer is A

Explanation

The correct answer is A. Emotional lability.

A. Emotional lability: Emotional lability refers to rapid and unpredictable changes in mood, with intense emotions shifting quickly from one extreme to another. It is a common aspect of the emotional adaptation to pregnancy and is often influenced by hormonal changes.

B. Focusing phase: The focusing phase is a concept related to the process of adapting to pregnancy. It involves the pregnant individual focusing on the reality of the pregnancy and incorporating the changes into their self-concept. While mood changes may occur during this phase, the client's statement more specifically reflects emotional lability.

C. Cognitive restructuring: Cognitive restructuring involves changing thought patterns to modify emotional responses. The client's statement does not necessarily indicate a deliberate process of changing thought patterns but rather describes the emotional swings often associated with pregnancy.

D. Couvade syndrome: Couvade syndrome refers to a phenomenon where a partner experiences symptoms that mimic pregnancy symptoms. It is not applicable in this context as the client is describing her own emotional experiences related to pregnancy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

Correct Answer is A

Explanation

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps, placing them in the order of performance. Use all the steps.)

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of 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 is planning care for a client in active labor whose fetus is in an occipital brow presentation. Which of the following complications should the nurse anticipate as a result of this fetal presentation?

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 caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?