Try Naxlex NCLEX-RN (Free-Trial)

A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Obtain a baseline reading of the FHR and contraction pattern.

Document the procedure in the electronic medical record.

Pass the sterile hook to the provider.

Position the client with a rolled towel under her hips

Check the fluid for color, odor, and consistency

Answer and Explanation

The Correct Answer is A,D,C,E,B

A. Obtain a baseline reading of the FHR and contraction pattern.
- Establishing a baseline of fetal heart rate (FHR) and contraction pattern is crucial to assess for any immediate changes following the amniotomy.
D. Position the client with a rolled towel under her hips.
- Positioning the client with a rolled towel under her hips helps to relieve pressure on the vena cava, improve uterine blood flow, and optimize fetal positioning.
C. Pass the sterile hook to the provider.
- The sterile hook is used to break the amniotic sac, and the nurse should pass it to the provider during the procedure.
E. Check the fluid for color, odor, and consistency.
- After the amniotomy, the nurse should assess the amniotic fluid for color (should be clear), odor (should be odorless), and consistency to check for any signs of meconium or infection.
B. Document the procedure in the electronic medical record.
- The nurse should document the amniotomy procedure and any findings (e.g., FHR changes, amniotic fluid assessment) in the medical record after the procedure has been completed.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.

B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.

C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.

D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.

A. Pain in the right upper abdomen B. Discomfort with urination C. Pain radiating to the jaw D. Increased abdominal discomfort prior to meals

Correct Answer is A

Explanation

A. Pain in the right upper abdomen is correct. Acute cholecystitis is the inflammation of the gallbladder, typically caused by gallstones blocking bile flow. This condition leads to severe right upper quadrant (RUQ) pain, often triggered by fatty meals and sometimes accompanied by nausea, vomiting, and fever.

B. Discomfort with urination is incorrect. Urinary discomfort is not associated with cholecystitis. This symptom is more indicative of urinary tract infections (UTIs) or kidney stones.

C. Pain radiating to the jaw is incorrect. Jaw pain is more characteristic of cardiac conditions, such as myocardial infarction (MI), rather than gallbladder inflammation.

D. Increased abdominal discomfort prior to meals is incorrect. Clients with cholecystitis typically experience more pain after meals, especially fatty foods, due to gallbladder contractions attempting to release bile.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a terminal illness. The client states, "I wish I would die now." Which of the following responses should the nurse make?

A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse expect?

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family?

A charge nurse is reinforcing teaching with a newly licensed nurse about the nurse's role in obtaining informed consent. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who has a new prescription for warfarin. The nurse should identify which of the following over-the-counter medications as safe for use with warfarin?

A nurse is caring for a client who has Graves' disease. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?