A nurse in a labor unit is admitting a patient who reports experiencing painful contractions. The nurse determines that the contractions last for 1 minute and occur every 3 minutes.The nurse records the following vital signs: fetal heart rate of 130/min, maternal heart rate of 128/min, and maternal blood pressure of 92/54 mm Hg. What should the nurse prioritize doing next?

Notify the provider of the findings.

Ask the patient if she needs pain medication.

Have the patient void.

Position the patient with one hip elevated.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Given the frequency and duration of the contractions, along with the maternal and fetal vital signs, it is important to notify the healthcare provider immediately. These could be signs of labor progression and the healthcare provider can provide further instructions based on the clinical situation.
Choice B rationale
While managing pain is important, the priority in this situation is to communicate with the healthcare provider due to the frequency of contractions and the vital signs.
Choice C rationale

Having the patient void is not the priority in this situation. While a full bladder can affect labor progression, the frequency of contractions and the vital signs take precedence.
Choice D rationale
Positioning the patient with one hip elevated is not the priority in this situation. This position is often used to alleviate supine hypotensive syndrome, but the patient’s blood pressure is not indicating this condition.

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Correct Answer is D

Explanation

Choice A rationale
The palpability of the posterior fontanel is not related to the position of the fetus.
Choice B rationale
The level of the ischial spines refers to the station of the fetus, not its position.
Choice C rationale
The passage of the largest fetal diameter through the pelvic outlet is a stage of labor, not a fetal position.
Choice D rationale
This is the correct answer. The left occiput posterior position refers to the position of the fetal head.

A. Fundus at the level of the umbilicus B. Deep tendon reflexes 4+ C. Saturated perineal pad in 30 minutes D. Approximated edges of the episiotomy

Correct Answer is C

Explanation

Choice A rationale
A fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum.
Choice B rationale
Deep tendon reflexes of 4+ could indicate hyperreflexia, a sign of preeclampsia, but this is not the priority if the client has a saturated perineal pad in 30 minutes.
Choice C rationale
A saturated perineal pad in 30 minutes indicates heavy bleeding, which could be a sign of postpartum hemorrhage. This is a life-threatening condition and is therefore the priority.
Choice D rationale
Approximated edges of the episiotomy is a normal finding in a woman who is 4 hours postpartum.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is examining a client who is in active labor and observes that the presenting part is in the left occiput posterior position. What is the clinical interpretation of this finding?

Correct Answer is D

Explanation

A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

Correct Answer is C

Explanation

A nurse in a prenatal clinic is caring for a client whose blood pressure is 80/40 mm Hg. The client’s last menstrual period was on May 4, 2023. What would be the estimated due date for the client?

A nurse is planning care for a patient who is 2 hours postpartum following a cesarean birth. The patient has a history of thromboembolic disease.Which nursing interventions should be included in the plan of care?

A nurse is assessing a newborn who has Trisomy 21 (Down’s Syndrome). Which of the following are common characteristics? (Select all that apply.)

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply)

A nurse in the newborn unit is caring for several infants. Which of the following situations requires the nurse's immediate attention and intervention?

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?