A patient’s lab results are as follows: BUN level is 8 mg/dL, Hemoglobin is 15 g/dL, Hematocrit is 47%, WBC count is 9,000/mm, Platelet count is 140,000/mm, Creatinine is 1.3 mg/dL, Bilirubin is 20 mg/dL, Aspartate aminotransferase (AST) is 36 units/L, and Alanine aminotransferase (ALT) is 40 units/L. What actions should be taken?

Implement seizure precautions.

Check deep tendon reflexes every hour.

Review the daily logs of the patient.

Obtain a prescription for methyldopa.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Implementing seizure precautions is not necessary based on these lab results. Seizure precautions are typically implemented for patients with a known seizure disorder or those who are at risk for seizures, such as patients with severe preeclampsia or eclampsia, neither of which can be diagnosed based on these lab results.
Choice B rationale
Checking deep tendon reflexes every hour is not indicated based on these lab results. This action is typically taken for patients with altered neurological status or those receiving certain medications that can affect muscle tone.
Choice C rationale
Reviewing the daily logs of the patient is a good practice in general to monitor the patient’s progress and response to treatment. However, it is not a specific action that should be taken based on these lab results.
Choice D rationale
Obtaining a prescription for methyldopa is not indicated based on these lab results.
Methyldopa is a medication used to treat high blood pressure, and there is no indication from these lab results that the patient has high blood pressure.

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Correct Answer is D

Explanation

Choice A rationale
Administering oxygen via face mask is a common intervention for various complications during labor. However, it is not the priority action when late decelerations are observed on the fetal monitor. Late decelerations are a sign of fetal hypoxia, which is often caused by uteroplacental insufficiency. While oxygen administration can help increase the overall oxygen available, it does not directly address the cause of the late decelerations.
Choice B rationale
Increasing the rate of the IV fluid infusion can help improve maternal circulation and potentially increase placental perfusion. However, this intervention is not the most immediate or effective response to late decelerations.
Choice C rationale
Elevating the client’s legs is not the recommended action in response to late decelerations. This position does not alleviate the cause of late decelerations and can actually impede blood flow to the uterus.
Choice D rationale
Positioning the client on her side, specifically the left side, is the priority action when late decelerations are observed. This position helps to maximize blood flow to the uterus and placenta, thereby improving oxygen delivery to the fetus.

A. Fetal head compression. B. Umbilical cord compression. C. Uteroplacental insufficiency. D. Maternal bradycardia.

Correct Answer is C

Explanation

Choice A reason:

Fetal head compression is associated with early decelerations, not late. Early decelerations are a normal finding during labor as the fetal head is compressed during contractions, leading to a vagal response that temporarily decreases the heart rate.

Choice B reason:

Umbilical cord compression leads to variable decelerations, not late. Variable decelerations can occur at any time during the contraction cycle and are caused by compression of the umbilical cord, which can restrict blood flow to the fetus.

The correct answer is C. Uteroplacental insufficiency.

Late decelerations are indicative of uteroplacental insufficiency, which is a condition where the placenta is not delivering enough oxygen and nutrients to the fetus.

Choice D reason:

Maternal bradycardia, which is a slower than normal heart rate in the mother, does not cause late decelerations in the fetus. Instead, maternal bradycardia can be a separate concern and does not directly affect the fetal heart rate pattern observed on the monitor.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor. What should be the nurse’s priority action?

Correct Answer is D

Explanation

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Correct Answer is C

Explanation

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

A nurse is caring for a client who is at 36 weeks of gestation and suspected of having placenta previa. Which of the following symptoms would support this diagnosis?

A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. Which of the following explanations about this test should the nurse provide to the client?

A nurse is attending to a patient in labor who has received an epidural anesthesia block. The patient’s blood pressure reads 80/40 mm Hg and the fetal heart rate is 140/min. What should be the nurse’s immediate course of action?

A nurse is preparing to administer methylergonovine IM to a client who has just had a vaginal delivery. The nurse should inform the client that this medication is intended to prevent which of the following conditions?

A nurse in a prenatal clinic is caring for a pregnant client who inquires about her estimated date of birth (EDB). If the client’s last menstrual period started on July 27, what would be the client’s EDB? (Provide the date in MMDD format. For example, July 27 is 0727) .

A nurse is caring for a patient who is about to undergo a biophysical profile. The patient asks the nurse what aspects are evaluated during this test. Which of the following should the nurse include? (Select all that apply)