A client presents to L & D for evaluation. Upon placing her on the electronic fetal monitor (EFM), the nurse finds the fetal heart rate (FHR) to be consistently 170 to 180 bpm. What should the nurse do first?

Apply oxygen at 10 L/min by face mask

Prepare for cesarean delivery

Take the mother’s temperature

Apply a FSE

Answer and Explanation

The Correct Answer is C

A. Apply oxygen at 10 L/min by face mask:
Not first. While oxygen can help, the underlying cause must be assessed before intervention.

B. Prepare for cesarean delivery:
Not appropriate yet; initial assessment must be completed first to determine cause of tachycardia.

C. Take the mother’s temperature:
Maternal fever is a common cause of fetal tachycardia and must be ruled out first.

D. Apply a FSE:
Invasive and not the first step. It is done when external monitoring is inadequate, not as an initial assessment.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus: This describes uterine souffle, not Goodell's sign.

B. Softening of the lower segment of the uterus: This is Hegar’s sign.

C. Bluish discoloration of the cervix: This is Chadwick’s sign.

D. Softening of the vaginal segment of the cervix: Goodell’s sign is softening of the cervix due to increased vascularity.

A. Abdominal wall relaxes noticeably and the cord shortens B. Uterus falls below the level of the symphysis pubis and becomes globular C. Cord lengthens outside the vagina with a gush of blood D. Client complains of the urge to push and you see the uterus shrink

Correct Answer is C

Explanation

A. Abdominal wall relaxes noticeably and the cord shortens
Cord shortening is not a sign of placental separation; it should lengthen.

B. Uterus falls below the level of the symphysis pubis and becomes globular
The uterus rises slightly and becomes globular, not falls.

C. Cord lengthens outside the vagina with a gush of blood
Classic signs of placental separation include a sudden gush of blood and visible cord lengthening.

D. Client complains of the urge to push and you see the uterus shrink
Urge to push may occur in labor but does not indicate placental separation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client presents to L & D for evaluation. Upon placing her on the electronic fetal monitor (EFM), the nurse finds the fetal heart rate (FHR) to be consistently 170 to 180 bpm. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of Goodell's sign. The nurse determines this sign indicates:

Correct Answer is D

Explanation

The nurse prepares prescribed oxytocin, which is to be added to the client's IV fluid when the placenta has been delivered. The nurse determines the placenta has separated and is about to be delivered when which of the following happens?

Correct Answer is C

Explanation

A pregnant client visits for her first check up and states she had a boy at 30 weeks that died of SIDS, a baby at 39 weeks, an ectopic pregnancy at 11 weeks, and a miscarriage at 22 weeks. Identify the parity using GTPAL

The nurse is interviewing a client who sates that she is pregnant. What are some presumptive signs of pregnancy? Select all probable signs of pregnancy.

The nurse understands that variability in the FHR is indicative of which of the following?

During the fetal circulation, which of the following connects the main pulmonary artery to the aorta?

A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie?

The nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hours. Which of the following statements by the nurse indicates the rational for this request?

A client in the second trimester of pregnancy tells the nurse that she has developed a darkened line in the midline of her abdomen from the symphysis pubis to the umbilicus. Which of the following are other expected changes during pregnancy that might be noticeable to the client?

Leopolds maneuvers are used to assess the fetal presentation, dilation, and station.