A patient in the latent phase of labor begins to experience nausea, feelings of helplessness and has become very irritable. The nurse suspects that the patient is now in the

Not satisfied with the nonpharmacological comfort measures

active phase of labor

Going to require more pain medication

Going to have a long labor

Answer and Explanation

The Correct Answer is B

A. Not satisfied with the nonpharmacological comfort measures. This describes dissatisfaction with pain management but does not specifically indicate a change in labor phase.

B. Active phase of labor. Nausea, irritability, and feelings of helplessness are classic signs of transitioning from the latent phase to the active phase of labor, when contractions become stronger and more intense.

C. Going to require more pain medication: Although the patient may need additional pain relief, the question is asking about labor progression, not pain management.

D. Going to have a long labor. Irritability and nausea are signs of labor progression, not necessarily an indicator of a long labor.

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Correct Answer is D

Explanation

A. Heart rate of 55/min. A heart rate of 55/min is bradycardia, which may indicate magnesium toxicity. This is a concerning sign and does not indicate safety to continue.

B. Urine output of 50 mL in 4 hr. A urine output of only 50 mL in 4 hours is too low (less than 30 mL/hr is concerning) and may indicate toxicity, since magnesium sulfate is excreted via the kidneys.

C. Diminished deep-tendon reflexes. Diminished deep-tendon reflexes (DTRs) may indicate magnesium toxicity. DTRs are monitored to assess for toxicity.

D. Respiratory rate of 16/min. A normal respiratory rate (12-20 breaths per minute) indicates that the magnesium sulfate has not caused respiratory depression, a sign of magnesium toxicity.

A. Check the fluid with Nitrazine paper B. Assess the FHR C. Note the color of the fluid D. Notify the health care provider

Correct Answer is B

Explanation

A. Check the fluid with Nitrazine paper. While this test can confirm if the membranes have ruptured, assessing the fetal heart rate (FHR) is more critical to ensure that there is no fetal distress due to umbilical cord prolapse.

B. Assess the FHR. After suspected rupture of membranes, the priority is to assess the fetal heart rate to check for potential complications like umbilical cord prolapse, which can cause fetal distress.

C. Note the color of the fluid. Assessing the color of the fluid is important, especially if meconium is present, but it is secondary to ensuring fetal well-being by assessing the FHR first.

D. Notify the health care provider. The provider should be notified, but the first action should be to assess the fetal heart rate to check for signs of distress.

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A patient in the latent phase of labor begins to experience nausea, feelings of helplessness and has become very irritable. The nurse suspects that the patient is now in the

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Naxlex Comprehensive Predictor Exams

. nurse is assisting with the care of a client with PROM and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

Correct Answer is D

Explanation

A laboring patient reports to the nurse that "I think my water just broke!" The first action the nurse should take is:

Correct Answer is B

Explanation

What is measured from the beginning of one contraction to the beginning of the next contraction?

What is the most common cause of early decelerations in fetal heart rate?

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?

A nurse is reading a Fetal monitor strip and notes accelerations. What interventions would the nurse anticipate to do next?

A disadvantage of internal fetal monitoring is:

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?