A primigravida client at 36-weeks gestation is admitted to the labor and delivery unit because her membranes ruptured 30 minutes ago. Initial assessment indicates a 2 cm cervical dilatation, 50% effaced, -2 station, vertex presentation, greenish-colored amniotic fluid, and contractions occurring every 3 to 5 minutes, with a decrease in fetal heart rate after the last four contraction peaks. Which action should the nurse implement first?

Administer oxygen via face mask.

Apply an Internal fetal heart monitor.

Notify the healthcare provider.

Use a vibroacoustic stimulator.

Answer and Explanation

The Correct Answer is A

A.   Administer oxygen via face mask. The decrease in fetal heart rate after contractions indicates possible fetal distress. Administering oxygen to the mother can increase oxygen delivery to the fetus, potentially improving fetal oxygenation and alleviating distress.
B.   Apply an Internal fetal heart monitor. While continuous monitoring is important, the first priority is to address the immediate fetal distress. Monitoring alone will not address the issue.
C.   Notify the healthcare provider. Notifying the provider is important, but addressing the immediate fetal distress takes priority.
D.   Use a vibroacoustic stimulator. Vibroacoustic stimulation can be used to assess fetal well- being, but it does not address the underlying fetal distress, which is the priority.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. While scheduling a client and family conference may be necessary to discuss the plan of care, the immediate concern is to determine the type of advance directive the client has and whether it includes preferences regarding resuscitation.
B. This is the most appropriate action because it addresses the family member's concern and ensures that the client's wishes regarding resuscitation are understood and followed.
C. While checking for a DNR bracelet is important, it does not address the family member's question about why the code was called despite the client having a living will.
D. This statement is incorrect. Living wills can guide decision-making regarding end-of-life care, including resuscitation, depending on the legal requirements and documentation in place.

A. Begin parenteral antibiotic therapy. B. Administer antiemetic agents. C. Provide a high-calorie, high-protein diet. D. Bivalve the cast for distal compromise.

Correct Answer is A

Explanation

A. Begin parenteral antibiotic therapy.
This is the correct answer. Osteomyelitis is a serious bone infection that requires prompt and aggressive antibiotic therapy to prevent further complications and promote healing.

B. Administer antiemetic agents.
Antiemetic agents may be necessary if the client is experiencing nausea or vomiting, but this is not the priority action.

C. Provide a high-calorie, high-protein diet.
While nutritional support is important for healing, initiating antibiotic therapy to address the infection takes precedence.

D. Bivalve the cast for distal compromise.
Bivalving the cast might be necessary if there is evidence of compartment syndrome or impaired circulation, but there is no indication from the question that such a complication is present at this time.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

An adolescent client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. Which action should the nurse implement next?

Correct Answer is A

Explanation

Exhibits Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client's arm?

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the nurse to include in the assessment of this client?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to the practical nurse (PN)?

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?