“A nurse is caring for a patient who reports spontaneous rupture of membranes.

The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.

After calling for assistance and notifying the provider, which of the following actions should the nurse take next?”

“Initiate an infusion of IV fluids for the patient.”.

“Administer Oxygen via nonrebreather mask at 8L/min.”.

“Perform a vaginal examination by applying upward pressure on the presenting part.”.

“Cover the umbilical cord with a sterile saline saturated towel.”. .

Answer and Explanation

The Correct Answer is C

Choice A rationale
While initiating an infusion of IV fluids for the patient is important, it is not the immediate next step after noticing a protruding umbilical cord.
Choice B rationale
Administering oxygen via a nonrebreather mask at 8L/min is a later step in the management of umbilical cord prolapse.
Choice C rationale
The immediate next step after noticing a protruding umbilical cord is to perform a vaginal examination and apply upward pressure on the presenting part to relieve cord compression.
Choice D rationale
Covering the umbilical cord with a sterile saline-saturated towel is a later step in the management of umbilical cord prolapse.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale
Transient strabismus, or temporary misalignment of the eyes, is not typically a symptom observed in newborns exposed to opioids during pregnancy.
Choice B rationale
Mottling, or patchy skin color, is a common physical characteristic in newborns and is not specifically associated with opioid exposure during pregnancy.
Choice C rationale
A respiratory rate of 70/min is significantly higher than the normal range for a newborn, which is typically between 30 and 60 breaths per minute. This could be a sign of neonatal abstinence syndrome (NAS), a group of conditions caused by withdrawal from certain drugs that the newborn was exposed to in the womb.
Choice D rationale
Loose stools are not typically associated with opioid exposure during pregnancy.
Choice E rationale
Regurgitation, or spitting up, is common in newborns and is not specifically associated with opioid exposure during pregnancy.

A. “Thick, white vaginal discharge.”. B. “Vulva lesions.”. C. “Malodorous discharge.”. D. “Urinary frequency.”.

Correct Answer is C

Explanation

Choice A rationale
A thick, white vaginal discharge is more commonly associated with a yeast infection, not trichomoniasis.
Choice B rationale
Vulva lesions are not a typical symptom of trichomoniasis. They can be associated with other conditions such as herpes.
Choice C rationale
Trichomoniasis is a sexually transmitted infection caused by a parasite. One of the common symptoms in women is a foul-smelling vaginal discharge, which can be clear, white, yellowish, or greenish.
Choice D rationale
While urinary frequency can occur with trichomoniasis, it is not as specific or common as malodorous discharge.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a term newborn who is 48 hours old. The mother has a history of opioid use during pregnancy and was prescribed methadone. Based on the findings 24 hours later, how should the nurse interpret the findings?

Correct Answer is C

Explanation

“A nurse is caring for a patient who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?”

Correct Answer is C

Explanation

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?

A nurse is planning care for a client who is 1 hour postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus (MRSA). Which type of isolation precautions should the nurse initiate?

A nurse is caring for a client who is at 6 weeks of gestation and reports nausea and vomiting. Which of the following recommendations should the nurse make?

A nurse is collecting data from a client who is at 30 weeks of gestation. Which finding should the nurse identify as a manifestation of pyelonephritis?

A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?