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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "Wearing an underwire bra between feedings" can compress the breast tissue, potentially leading to milk stasis and increasing the risk of mastitis.

B. "Covering your breasts immediately after feedings" can trap moisture and warmth, creating an environment conducive to bacterial growth and increasing the risk of mastitis.

C. "Applying cold compresses to your breasts before feedings" may provide temporary relief for discomfort, but it is not a primary preventive measure for mastitis.

D. "Trying to have your baby empty your breasts with each feeding" helps ensure thorough milk removal, which can prevent milk stasis and decrease the risk of mastitis. This is the correct choice.

A. Repeats the words of others when speaking B. Speaks in word salad C. Expresses interest in ADLs (Activities of Daily Living) D. Has a blunt affect E. Experiences delusions

Correct Answer is ["A","B","D","E"]

Explanation

A. Echolalia, or repeating the words of others, can be a manifestation of schizophrenia.

B. Word salad, or a jumble of incoherent words and phrases, can occur in schizophrenia.

C. Expressing interest in ADLs is not typically associated with schizophrenia and may indicate a different mental health state.

D. A blunt affect, or reduced emotional expression, is a common symptom of schizophrenia.

E. Delusions, or fixed false beliefs, are a hallmark symptom of schizophrenia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following Instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia. The nurse should expect the client to exhibit which of the following manifestations? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

A nurse discovers that the wrong dosage of a medication was given to a client. When determining what action to take, the nurse should recognize that which of the following ethical principles should be applied?

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

A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly?

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

A nurse is analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit?

Exhibits A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first?