A nurse is caring for a client who is nulliparous and in the first stage of labor. The last
internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?

Perform another internal exam.

Notify the client's provider.

Check the FHR.

Obtain a pH test of the fluid.

Answer and Explanation

The Correct Answer is C

A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.

B. Notifying the client's provider may be necessary, but it is not the immediate priority.

C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.

D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.

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Correct Answer is A

Explanation

A. Adequate hydration helps maintain skin integrity and reduces the risk of pressure injuries by keeping the skin hydrated and resilient.

B. Moisturizing dry skin is important for overall skin health but may not directly prevent pressure injuries.

C. While maintaining a comfortable room environment is important for the client's overall well- being, a dehumidifier specifically may not directly prevent pressure injuries.

D. Donut ring pillows are not recommended for pressure injury prevention as they can actually increase pressure on vulnerable areas of the skin, leading to tissue damage.

A. Take the client to the bathroom to void. B. Ask the client to verify the surgical site. C. Review deep breathing and coughing exercises. D. Raise the side rails on the bed.

Correct Answer is B

Explanation

A. While it's important for the client to empty their bladder before surgery to reduce the risk of complications, administering a preoperative injection typically requires monitoring the client closely for any adverse reactions rather than immediately taking them to the bathroom.

B. Asking the client to verify the surgical site helps prevent wrong-site surgery and ensures proper patient safety protocols are followed.

C. Reviewing deep breathing and coughing exercises is an important preoperative teaching, but it's not typically done immediately after administering a preoperative injection.

D. Raising the side rails on the bed is a safety measure to prevent falls, but it's not directly related to administering a preoperative injection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?

Correct Answer is A

Explanation

A nurse is preparing a client for surgery and has just administered the preoperative injection.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern?

A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge?

A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?

A nurse in a postpartum unit is caring for several clients. After receiving a change-of-shift report, which of the following clients should the nurse assess first?

A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods?

A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?

A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?