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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale

The statement about shock waves refers to a different procedure called extracorporeal shock wave lithotripsy, which is used to break up kidney stones and gallstones. It is not related to an oral cholangiogram.

Choice B rationale

An oral cholangiogram does not involve inserting a camera down the throat. This statement seems to refer to an endoscopic procedure, which is different from an oral cholangiogram.

Choice C rationale

This statement is correct. An oral cholangiogram is an X-ray examination of the gallbladder and bile ducts. The patient takes an oral medication that makes these structures more visible on the X-ray.

Choice D rationale

This statement is incorrect. An oral cholangiogram does not involve putting medication into the gallbladder to dissolve stones. This seems to refer to a different treatment approach.

A. Respiratory distress B. Sudden infant death syndrome C. Congenital anomalies D. Low birth weight

Correct Answer is B

Explanation

Choice A rationale

While respiratory distress can be a serious condition in infants, it is not the leading cause of death among this age group. Other conditions, such as sudden infant death syndrome and complications from premature birth, are more common causes of death in infants.

Choice B rationale

Sudden Infant Death Syndrome (SIDS) is indeed a leading cause of death among infants. It is a significant health concern and a major cause of post-neonatal death. SIDS is the unexplained death, usually during sleep, of a seemingly healthy baby less than a year old.

Choice C rationale

Congenital anomalies can cause death in infants, but they are not the leading cause. Conditions such as SIDS and complications from premature birth are more common causes of infant death.

Choice D rationale

Low birth weight can contribute to health problems in infants and increase the risk of infant mortality. However, it is not the leading cause of death among infants. Conditions such as SIDS and complications from premature birth are more common causes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a patient diagnosed with cholelithiasis about the upcoming oral cholangiogram.Which statement by the patient indicates that the education was effective?

Correct Answer is C

Explanation

A nurse is providing health promotion teaching to the parents of an infant.Which of the following conditions should the nurse identify as the leading cause of death among this age group?

Correct Answer is B

Explanation

A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition.Which of the following instructions should be included?

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?

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor.The client has a new prescription for magnesium sulfate.Which of the following explanations should the nurse provide about the purpose of this medication?

A 23 weeks pregnant client calls the clinic and reports leakage of vaginal fluid.What should be the appropriate response by the nurse?

A nurse is caring for a client who has just been admitted to the medical-surgical unit from the emergency department.The nurse is reviewing the client’s medical records.Which of the following conditions is the client most likely experiencing, based on the client’s notes and actions to be taken?

A nurse is caring for a newborn who is 8 hours old.Based on the information in the newborn’s medical record, the nurse determines that the newborn is at risk for developing which of the following complications?

A nurse is developing a care plan for a patient who has been diagnosed with idiopathic thrombocytopenic purpura (ITP). Which of the following symptoms is most important for the nurse to monitor?