A nurse is caring for a client who is pregnant.

The client’s vital signs are as follows: Temperature 37.2°C (98.9°F), Pulse rate 80/min, Respiratory rate 16/min, Blood Pressure 120/69 mm Hg. What should the nurse monitor next?

Fetal heart rate.

Uterine contractions.

Amniotic fluid levels.

Cervical dilation.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Monitoring the fetal heart rate is the next appropriate action. The fetal heart rate provides crucial information about the fetus’s well-being and can help identify any potential issues that may need further intervention.
Choice B rationale
Monitoring uterine contractions is important, but in this scenario, the client’s vital signs are stable, and there is no indication of labor. Therefore, monitoring the fetal heart rate takes precedence.
Choice C rationale
Amniotic fluid levels are important to monitor, but they are typically assessed through ultrasound rather than immediate bedside monitoring. The fetal heart rate provides more immediate information about the fetus’s condition.
Choice D rationale
Cervical dilation is relevant during labor, but there is no indication that the client is in labor based on the provided vital signs. Monitoring the fetal heart rate is more pertinent in this situation.

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

Choice A rationale
Monitoring the patient’s vocalizations and facial expressions can provide some information about the intensity of contractions, but it is subjective and not a reliable method for accurately assessing contraction intensity.
Choice B rationale
Palpating the maternal abdomen during a contraction is the best method for determining the intensity of contractions. By feeling the firmness of the uterus, the nurse can assess whether the contractions are mild, moderate, or strong. This method provides a more objective measure of contraction intensity compared to other methods.
Choice C rationale
Timing the amount of time between the ending of one contraction and the beginning of the next provides information about the frequency of contractions, not their intensity. This choice does not address the question of how to determine contraction intensity.
Choice D rationale
Palpating the maternal abdomen right after a contraction does not provide information about the intensity of the contraction that just occurred. The uterus will be relaxed after the contraction, making it difficult to assess the strength of the previous contraction.

A. Perform chest physiotherapy prior to suctioning B. Prelubricate the suction catheter tip with sterile saline when suctioning the airway. C. Hyperventilate the client with 100% oxygen before suctioning the airway. D. Provide humidified oxygen.

Correct Answer is D

Explanation

A. Chest physiotherapy can help mobilize secretions, but it primarily aids in clearing secretions rather than directly thinning them. While it may be beneficial as part of a comprehensive approach, it is not the most direct method for thinning secretions.
B. Prelubricating the suction catheter with saline does not effectively thin secretions. In fact, using saline in this way may introduce moisture that could inadvertently lead to complications, such as introducing infection or causing the client to cough.
C. While hyperventilation and providing oxygen are important for maintaining oxygen saturation during suctioning, this method does not help in thinning secretions. It may be used to ensure oxygenation during suctioning but is not effective for secretion management.
D. Providing humidified oxygen is an effective way to thin secretions. Humidity adds moisture to the airways, which can help to keep secretions less viscous and easier to clear. This is a standard practice in managing secretions in clients with tracheostomies.

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 caring for a client who is pregnant. The client’s vital signs are as follows: Temperature 37.2°C (98.9°F), Pulse rate 80/min, Respiratory rate 16/min, Blood Pressure 120/69 mm Hg. What should the nurse monitor next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing preceptor asks the nursing student how to determine the intensity of contractions before placing the client on the electronic fetal monitor. What is the best explanation?

Correct Answer is B

Explanation

A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

Correct Answer is D

Explanation

A nurse is preparing to administer Terbutaline 0.25 mg SQ to a client for tachysystole. Available is terbutaline injection 5 mg/mL. How many mL should the nurse administer? (Use a leading zero if it applies. Do not use a trailing zero.)

The labor and delivery nurse is caring for a client in active labor. The nurse notes the fetal heart rate baseline is 175 bpm, moderate variability, accelerations are absent and no decelerations noted. How should the nurse describe this tracing to the medical provider?

The nurse observes variable decelerations on the fetal monitor tracing. Which of the following is a correct interpretation of this finding?

The nurse is caring for a client. Which of the following findings would the nurse report to the anesthesia provider?

A nurse is educating a client about a contraction stress test. Which of the following is correct regarding the contraction stress test?

A nurse is caring for a client who is pregnant.

The client’s vital signs are as follows: Temperature 37.2°C (98.9°F), Pulse rate 80/min, Respiratory rate 16/min, Blood Pressure 120/69 mm Hg. What should the nurse monitor next?