While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate during the contraction's peak, with the nadir of the decelerations occurring when the contraction end. The nurse's first priority is to:
Select one:

Insert a scalp electrode.

Notify the care provider.

Assist with amnioinfusion.

Reposition the patient.

Answer and Explanation

The Correct Answer is D

a. A scalp electrode is not indicated unless there is a problem with the external monitor tracing or if further assessment of the fetal heart rate variability is needed.
b. This is important but repositioning the patient is the priority.

c. Amnioinfusion is only done if repositioning the patient does not resolve the late decelerations.

d. The nurse is observing late decelerations of the fetal heart rate, which indicate uteroplacental insufficiency and fetal hypoxia. The nurse's first priority is to reposition the patient to improve placental blood flow and oxygen delivery to the fetus. Repositioning can be done by turning the patient to her side, elevating her legs, or placing a wedge under her hip.

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Correct Answer is A

Explanation

a. Bulging of the vulva: This indicates that the fetal head is descending but does not necessarily mean the woman is almost ready to give birth. This indicates that the fetal head is crowning and putting pressure on the perineum, which means that delivery is imminent.
b. This indicates that the amniotic sac has ruptured but does not necessarily mean the woman is almost ready to give birth.
c. The fetal head at 0 station means that it is at the level of the maternal ischial spines, but it still needs to descend further to reach the perineum.
d. This indicates that the woman is in the early stages of labor but does not necessarily mean she is almost ready to give birth.

A. Continuous fetal monitoring B. Obtain a daily weight. C. c Assess deep tendon reflexes every hour. D. Ambulate as tolerated

Correct Answer is D

Explanation

a. This is an appropriate order for a client with severe preeclampsia to monitor fetal well-being.
b. This is an appropriate order for a client with severe preeclampsia to monitor fluid status.
c. This is an appropriate order for a client with severe preeclampsia to monitor for signs of worsening preeclampsia.
d. This order may not be appropriate for a client with severe preeclampsia who may be at risk for falls or other complications. The nurse should clarify this order with the provider.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth Select one:

Correct Answer is A

Explanation

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

Correct Answer is D

Explanation

During the physical examination for the first prenatal visit, it is noted that Chadwick's sign is present. What is the interpretation of Chadwick's sign? Select one:

A nurse in a prenatal clinic is teaching a client who has a new prescription for Dinoprostone gel. Which of the following statements should the nurse include in the teaching? Select one:

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

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) baseline is around 130 beats/min, with four accelerations in 20 minutes, lasting 20 seconds each and the FHR increased more than 25 bpm. Which of the following actions should the nurse perform?

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action?