“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 B

Explanation

Choice A rationale
Taking a multivitamin daily is generally recommended during pregnancy to ensure the mother and baby receive necessary nutrients. It does not indicate a need for referral to a dietitian.
Choice B rationale
A weight gain of 4.5 kg (10 lb) since a positive pregnancy test could be a concern depending on the timeframe. If this weight gain occurred rapidly, it could indicate issues such as fluid retention or inadequate nutrition, which would warrant a referral to a dietitian.
Choice C rationale
Nausea, particularly in the morning, is a common symptom of early pregnancy often referred to as “morning sickness”. It does not typically require dietary intervention unless it is severe (hyperemesis gravidarum), leading to weight loss and dehydration.
Choice D rationale
Eating prunes is a natural method to manage constipation, a common issue during pregnancy due to hormonal changes that slow digestion. This choice does not indicate a need for a dietitian referral.

A. “Hold the finger above the heart prior to puncture.”. B. “Smear the blood onto the reagent strip.”. C. “Puncture the finger while still damp with antiseptic solution.”. D. “Select the lateral side of the finger for puncture.”.

Correct Answer is D

Explanation

Choice A rationale
Holding the finger above the heart prior to puncture does not affect the accuracy of a blood glucose test.
Choice B rationale
Smearing the blood onto the reagent strip can result in inaccurate readings.
Choice C rationale
Puncturing the finger while still damp with antiseptic solution can cause discomfort and potentially contaminate the sample.
Choice D rationale
Selecting the lateral side of the finger for puncture is recommended because it is less painful and has good blood flow.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a nutritional assessment for a client during their first prenatal visit at 12 weeks of gestation. Which of the following findings indicates that the client should be referred to a registered dietician?

Correct Answer is B

Explanation

“A nurse is obtaining a 2-hr postprandial blood glucose from a patient. Which of the following actions should the nurse take?”

Correct Answer is D

Explanation

A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client in a hands-and-knee position. Which should the nurse ask to evaluate the effectiveness of this intervention?

A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?

A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?

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 assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

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 providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?