A nurse in the labor unit is admitting a patient who reports experiencing painful contractions.
The nurse determines that the contractions last 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 is the nurse’s priority action?

Have the patient void.

Ask the patient if she needs pain medication.

Turn the patient on her side and recheck the blood pressure.

Notify the healthcare provider of the findings.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.

Choice B rationale

Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.

Choice C rationale

Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.

Choice D rationale

Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.

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Correct Answer is D

Explanation

Choice D rationale

Moving the client to a room closer to the nurses’ station is an appropriate action to address the safety needs of an older adult client who is becoming increasingly restless and intermittently confused. This allows for closer observation and quicker intervention if needed.

A. Call the Doctor. B. Administer diazepam. C. Obtain a medical history. D. Raise the side rails of the bed.

Correct Answer is B

Explanation

Choice A rationale

While it is important to notify the doctor, it is not the first action. The priority is to manage the patient’s symptoms and ensure their safety.

Choice B rationale

Administering diazepam is the correct first action. Delirium tremens is a severe form of alcohol withdrawal that can cause dangerous changes in breathing, blood pressure, and heart rate. Benzodiazepines like diazepam are the first line of treatment.

Choice C rationale

Obtaining a medical history is important, but it is not the first action. The priority is to treat the patient’s symptoms and stabilize their condition.

Choice D rationale

Raising the side rails of the bed is important for patient safety, but it is not the first action. The priority is to treat the patient’s symptoms. Diabetic ketoacidosisDiabetic ketoacidosis Explore

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused.Which of the following actions should the nurse take to address the client’s safety needs?

Correct Answer is D

Explanation

A nurse in the emergency department is implementing a plan of care for an older adult patient who is experiencing delirium tremens.What is the first action the nurse should take?

Correct Answer is B

Explanation

A nurse is caring for a new mother who is concerned that her newborn’s eyes cross.Which of the following statements is a therapeutic response by the nurse?

A nurse is caring for a patient who has an active upper gastrointestinal bleed.After inserting a nasogastric (NG) tube into the patient, what findings should the nurse anticipate?

While assessing a pregnant primigravida client, the nurse identifies a probable sign indicating the softening of the lower uterine segment.Which of the following signs is the nurse likely to have observed?

A pregnant couple at 14 weeks gestation has just been told that they both are carriers of an autosomal-recessive disorder.The nurse who is providing genetic counseling should take which of the following actions?

When preparing a presentation for a senior center about age-related musculoskeletal changes, which of the following changes should be included?

A nurse is providing teaching for a client who is newly diagnosed with type 2 diabetes mellitus and has a prescription for glipizide.Which of the following statements best describes the action of glipizide?

A client’s prenatal laboratory findings reveal no immunity to rubella.The health care provider orders the rubella vaccine.The nurse concludes that teaching about this medication is effective when the client states which of the following?