A nurse is caring for a 28-year-old female client in the labor and delivery unit who is in the fourth stage of labor.A nurse is caring for a 28-year-old female client in the labor and delivery unit who is in the fourth stage of labor.

Exhibits

Complete the following sentence by using the list of options. The nurse should first monitor the client's
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followed by the client's
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

The nurse should prioritize monitoring the client's fundal tone followed by the client's blood pressure. Here's why:

Fundal Tone: The client's fundus is boggy and not firming up with massage. This is a priority concern as it indicates uterine atony, which is a major cause of postpartum hemorrhage.
Blood Pressure: Monitoring blood pressure is crucial as the client is experiencing heavy lochia, and a decrease in blood pressure can indicate hypovolemic shock due to blood loss.

So, the completed sentence would be:

The nurse should first monitor the client's fundal tone followed by the client's blood pressure.

Taking care of immediate risks and stabilizing the patient is key in such cases.

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Correct Answer is A

Explanation

Choice A rationale

Checking the client's temperature frequently following the procedure is crucial. An amniotomy increases the risk of infection, so frequent monitoring of temperature helps in early detection and management of any potential infections.

Choice B rationale

Inserting misoprostol rectally every 2 hours following the procedure is not recommended. Misoprostol is a medication used for inducing labor or controlling postpartum hemorrhage, not for routine use post-amniotomy.

Choice C rationale

Obtaining a biophysical profile during the procedure is not relevant. A biophysical profile is an assessment of fetal well-being and is not typically performed during amniotomy.

Choice D rationale

Performing effleurage to the client's abdomen during the procedure is not necessary. Effleurage is a massage technique used for pain relief during labor, but it is not related to the management of an amniotomy. .

A. Heart rate 132/min. B. Report of headache. C. Nasal congestion. D. Tremors.

Correct Answer is A

Explanation

Choice A rationale

Terbutaline can cause tachycardia. A heart rate of 132/min is significantly higher than normal and could indicate severe cardiovascular effects.

Choice B rationale

While headaches can occur with terbutaline, they are generally not life-threatening and don't require immediate intervention compared to tachycardia.

Choice C rationale

Nasal congestion is a minor side effect and not a priority compared to a significantly elevated heart rate.

Choice D rationale

Tremors are common with terbutaline use, but they are usually not as concerning as a significantly elevated heart rate.

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Naxlex Comprehensive Predictor Exams

A charge nurse is preparing to discuss actions to take for clients who require an amniotomy during labor with a newly licensed nurse.Which of the following statements should the charge nurse include during the discussion?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously.Which of the following adverse effects is the priority for the nurse to report to the provider?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation and has a history of anemia.Which of the following results should the nurse identify and report as an indication of a prenatal complication?

A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic pregnancy.Which of the following actions should the nurse take?

A nurse is developing a plan of care for a client who is in the latent phase of labor.Which of the following interventions should the nurse include in the plan to manage the client's pain?

A nurse is performing a contraction stress test (CST) on a client who is at 40 weeks of gestation.The results of the test indicate a negative CST.Which of the following actions should the nurse take?

A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin.The client reports that they have been bleeding excessively.Which of the following actions should the nurse take?

A nurse is collecting a blood phenylketonuria (PKU) test for a newborn prior to discharge.The newborn's guardian asks the nurse what a positive PKU test would mean.Which of the following statements should the nurse make?