A nurse is caring for a client in the second stage of labor.

The nurse observes retraction of the fetal head against the maternal perineum after the fetal head is birthed.

What potential condition could the client be experiencing, what parameters should the nurse monitor to assess the client’s progress, and what actions should the nurse take?

Answer and Explanation

The Correct Answer is ["-"]

The nurse is observing a potential case of shoulder dystocia, a condition where the baby’s head has been delivered but one of the shoulders becomes stuck behind the mother’s pelvic bone. The nurse should monitor the mother’s vital signs and the baby’s heart rate. The nurse should call for immediate assistance, perform maneuvers to help deliver the baby, and prepare for a potential emergency cesarean section if necessary.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A rationale
The correct transcription of two tenths of a milligram is 0.2 mg. This format avoids any potential confusion that could lead to a medication error.
Choice B rationale
While 0.20 mg is technically correct, it is not the preferred format. The trailing zero after the decimal point is unnecessary and could potentially lead to confusion.
Choice C rationale
20 mg is not correct. This is 100 times the intended dose of two tenths of a milligram, and could lead to a serious medication error.
Choice D rationale
2 mg is not correct. This is 10 times the intended dose of two tenths of a milligram, and could lead to a medication error.

A. A provider can help you with that after a physical examination. B. Before I can help you, I need to know more about your sexual activity. C. You are so young. D. Are you ready for the responsibilities of a sexual relationship? E. Because of your age, I think that a barrier method would be the best choice.

Correct Answer is A

Explanation

Choice A rationale
This is the best response because it acknowledges the client’s question and refers her to a healthcare provider who can provide a comprehensive assessment and discuss the most appropriate contraceptive options for her specific situation.
Choice B rationale
While it’s important to understand a client’s sexual activity when discussing contraception, asking a minor about her sexual activity without a proper context or professional setting may be inappropriate and uncomfortable for the client.
Choice C rationale
This response may come off as judgmental or condescending. It’s crucial to provide a safe and non-judgmental environment when discussing sensitive topics like sexual health and contraception.
Choice D rationale
While barrier methods can be an effective form of contraception, it’s not appropriate to recommend a specific method without a thorough understanding of the client’s health history, lifestyle, and preferences.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage?

Correct Answer is A

Explanation

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. Which of the following medications should the nurse anticipate a prescription from the provider for the client?

A nurse is caring for a patient who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse suspects placenta previa. What would be an appropriate nursing action in this situation?

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

A nurse in labor and delivery is caring for a client. Following the delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

A nurse is caring for a patient who is about to undergo a biophysical profile. The patient asks the nurse what aspects are evaluated during this test. Which of the following should the nurse include? (Select all that apply)

A nurse in a healthcare provider’s office is caring for a patient who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

A nurse is preparing to administer methylergonovine IM to a client who has just had a vaginal delivery. The nurse should inform the client that this medication is intended to prevent which of the following conditions?

As a nurse in an antepartum unit performing triage, which client should be prioritized?