A first-time pregnant woman at 36 weeks of gestation is admitted to the labor and delivery unit because her membranes ruptured 30 minutes ago.

The initial assessment indicates a 2 cm cervical dilation, 50% effacement, -2 station, vertex presentation, greenish- colored amniotic fluid, and contractions occurring every 3 to 5 minutes.

There is a decrease in fetal heart rate after the last four contraction peaks.

What should the nurse do first?

Administer oxygen via a face mask.

Apply an internal fetal heart monitor.

Use a vibroacoustic stimulator.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Administering oxygen via a face mask is the first intervention the nurse should do. This is because the decrease in fetal heart rate after the last four contractions indicates possible fetal distress, which can be caused by insufficient oxygen. Administering oxygen to the mother can increase the amount of oxygen available to the fetus, potentially alleviating the distress.
Choice B rationale
Applying an internal fetal heart monitor can provide more accurate and continuous data about the fetal heart rate and contractions. However, this is usually not the first intervention because it is invasive and can only be done if the cervix is sufficiently dilated and the membranes have ruptured.
Choice C rationale
Using a vibroacoustic stimulator is a method used to wake a sleeping baby in the womb during a non-stress test. It is not typically used in response to signs of fetal distress during labor.

Choice D rationale
Notifying the healthcare provider is important when there are signs of fetal distress. However, the nurse has interventions, such as administering oxygen, that they can and should do immediately while the healthcare provider is being notified.

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Correct Answer is D

Explanation

Choice A rationale
Using a cushion when sitting can provide comfort but does not directly address the client’s electrolyte imbalance, elevated blood pressure, or weight gain.

Choice B rationale
Offering a high protein diet can be beneficial for clients with hepatic failure to support liver regeneration and prevent malnutrition. However, it does not directly address the client’s immediate issues.

Choice C rationale

Providing only distilled water does not address the client’s electrolyte imbalance, elevated blood pressure, or weight gain. In fact, it could potentially exacerbate electrolyte imbalances.

Choice D rationale
Documenting abdominal girth can help monitor for fluid accumulation (ascites), a common complication of hepatic failure that can contribute to weight gain and elevated blood pressure.

A. Leukocytes, neutrophils, and thyroxine. B. Serum potassium, calcium, and phosphorus. C. Erythrocytes, hemoglobin, and hematocrit. D. Blood pressure, heart rate, and temperature.

Correct Answer is B

Explanation

Choice A rationale
Monitoring leukocytes, neutrophils, and thyroxine is not the most crucial for a patient with end-stage renal disease (ESRD). While these lab values can provide information about the patient’s immune function and thyroid function, they do not directly relate to the patient’s renal function.
Choice B rationale
Monitoring serum potassium, calcium, and phosphorus levels is crucial for a patient with ESRD. These electrolytes are typically excreted by the kidneys, and their levels can become imbalanced in patients with ESRD. Imbalances can lead to serious complications, such as cardiac arrhythmias and bone disease.
Choice C rationale
Monitoring erythrocytes, hemoglobin, and hematocrit is important for a patient with ESRD, as these patients often develop anemia due to decreased erythropoietin production by the kidneys. However, these are not the only lab values that should be monitored in these patients.
Choice D rationale

Monitoring blood pressure, heart rate, and temperature is important for all patients, but these are not specific to patients with ESRD. Patients with ESRD are at risk for electrolyte imbalances, which can affect cardiac function, making monitoring of serum potassium, calcium, and phosphorus levels more crucial.

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Naxlex Comprehensive Predictor Exams

The nurse identifies an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours in a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Correct Answer is D

Explanation

Which laboratory test results should the nurse monitor in a patient who has end-stage renal disease (ESRD)?

Correct Answer is B

Explanation

The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery. What immediate action should the nurse take?

A patient with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. What schedule should the nurse follow to monitor the patient’s blood pressure after this procedure?

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What interventions should the nurse include in this client’s plan of care? Select all that apply.

The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility. Which outcome statement should the nurse include in the plan of care?

A nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. What should be the nurse’s immediate course of action?