A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum.
Which action should the nurse perform first?

Place the client in Trendelenburg.

Notify the operating room team.

Administer oxygen via face mask.

Administer a fluid bolus of 500 mL.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Placing the client in Trendelenburg position is the first action as it helps to relieve pressure off the umbilical cord by using gravity to shift the fetus away from the pelvis. This position helps to prevent cord compression and maintain blood flow to the fetus.

Choice B rationale

Notifying the operating room team is important but should be done after immediately addressing the umbilical cord prolapse to prevent fetal hypoxia. Initial physical intervention takes priority.

Choice C rationale

Administering oxygen via face mask is beneficial for the mother and fetus but is not the immediate first action. Positioning the client to relieve pressure off the umbilical cord is more urgent.

Choice D rationale

Administering a fluid bolus of 500 mL can help maintain maternal blood pressure, but it is not the first action. The priority is to reposition the client to prevent cord compression.

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Correct Answer is ["2.3"]

Explanation

Step 1 is to convert the child's weight from pounds to kilograms. 16 pounds ÷ 2.2 = 7.3 kg.

Step 2 is to calculate the total daily dose in mg. 25 mg/kg × 7.3 kg = 182.5 mg.

Step 3 is to determine the dose per administration, divided by 2 since the dose is given every 12 hours. 182.5 mg ÷ 2 = 91.25 mg.

Step 4 is to convert the dose from mg to mL using the concentration of the medication. 91.25 mg ÷ (200 mg/5 mL) = 91.25 ÷ 40 = 2.3 mL per dose. The answer is 2.3 mL.

A. Weight gain of 2 pounds (0.91 kg). B. 1+ edema on her lower extremities. C. Fundal height of 30 cm. D. Fetal heart rate of 110 beats/minute.

Correct Answer is C

Explanation

Choice A rationale

A weight gain of 2 pounds (0.91 kg) in a 34-week gestation multigravida is generally considered normal. During the third trimester, it is typical for a pregnant woman to gain around 0.5 to 1 pound per week. This weight gain helps support the growing fetus and prepare the mother's body for labor and breastfeeding. However, sudden or excessive weight gain could indicate fluid retention or preeclampsia, but a 2-pound gain alone is not necessarily a concern.

Choice B rationale

1+ edema on the lower extremities is a common finding during pregnancy, especially in the later stages. It is usually due to increased blood volume and pressure on the pelvic veins from the growing uterus, which can slow the return of blood from the legs. While some degree of edema is normal, particularly in the ankles and feet, it is important to monitor for sudden or severe swelling, which could be a sign of preeclampsia.

Choice C rationale

A fundal height of 30 cm at 34 weeks gestation is concerning because it is less than the expected measurement. Fundal height typically corresponds to gestational age in centimeters (±2 cm). Therefore, at 34 weeks, the expected fundal height would be between 32 and 36 cm. A smaller fundal height could indicate intrauterine growth restriction (IUGR), oligohydramnios, or other fetal development issues, which require further evaluation by the healthcare provider.

Choice D rationale

A fetal heart rate (FHR) of 110 beats per minute (bpm) is within the normal range for a fetus. The normal FHR typically ranges from 110 to 160 bpm. Although 110 bpm is on the lower end of the normal range, it is still considered acceptable. Significant deviations from the normal range, either too low (bradycardia) or too high (tachycardia), could indicate fetal distress and require immediate attention.

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A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["2.3"]

Explanation

A 34-week gestation multigravida comes to the clinic for her bimonthly appointment. Which assessment finding should the nurse report to the healthcare provider (HCP)?

Correct Answer is C

Explanation

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A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum.
Which action should the nurse perform first?