A primipara presents to the perinatal unit describing rupture of the membranes (ROM) occurring 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client’s contractions are irregular and mild. Based on this data, the nurse plans to monitor which sign more frequently than for the average laboring client?

Color of amniotic fluid.

Maternal temperature.

Deep tendon reflexes.

Maternal blood pressure.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Monitoring the color of amniotic fluid is crucial for assessing fetal well-being, but it is not the primary concern in the case of prolonged ROM. The focus should be on preventing maternal and fetal infection.

Choice B rationale

Maternal temperature should be monitored more frequently because prolonged ROM increases the risk of infection, particularly chorioamnionitis. Early detection of fever can prompt timely intervention to prevent complications.

Choice C rationale

Deep tendon reflexes are not directly affected by prolonged ROM. Monitoring them is more relevant for conditions like preeclampsia, where neurological assessment is critical. It is not the main concern in this scenario.

Choice D rationale

Maternal blood pressure is important to monitor but is not the primary focus in the context of prolonged ROM. The main concern is the increased risk of infection, necessitating closer monitoring of maternal temperature.

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 C

Explanation

Choice A rationale

Caput succedaneum is a benign, self-limiting condition and does not require direct pressure. It resolves on its own within a few days after birth. Applying pressure may cause unnecessary discomfort to the newborn.

Choice B rationale

A STAT CT scan of the head is not necessary for diagnosing cephalhematoma, which is a localized collection of blood between the skull and periosteum. CT scans are typically reserved for more severe neurological concerns.

Choice C rationale

A cephalhematoma, characterized by swelling that does not cross suture lines, requires notification of the pediatrician. It may increase the risk of hyperbilirubinemia and needs monitoring for potential complications.

Choice D rationale

While assessing neurological vital signs every 4 hours is important for overall newborn care, it does not address the specific condition of cephalhematoma. The primary concern is monitoring for complications such as jaundice.

A. Document the finding in the medical record. B. Schedule the client for a biophysical profile. C. Request another nurse measure the fundus. D. Notify the healthcare provider of the finding.

Correct Answer is B

Explanation

Choice A rationale

Documenting the finding in the medical record is routine, but it does not address the potential concern of the fundal height discrepancy, which may indicate a need for further evaluation.

Choice B rationale

Scheduling a biophysical profile is crucial to assess the well-being of the fetuses, especially given the discrepancy in fundal height, which could indicate issues such as growth restriction or polyhydramnios.

Choice C rationale

Requesting another nurse to measure the fundus might help verify the measurement but does not address the potential underlying issue, which requires further assessment like a biophysical profile.

Choice D rationale

Notifying the healthcare provider is necessary, but it is more appropriate to first schedule a biophysical profile to gather comprehensive information on the fetal well-being before consulting the provider.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?

Correct Answer is C

Explanation

A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?

Correct Answer is B

Explanation

A nurse is caring for a 24-year-old pregnant woman in the prenatal clinic. She is gravida 2, para 1 (G2P1), and her mother has a history of type 2 diabetes mellitus. Exhibits: Exhibits Which is likely causing this client's increased blood glucose at 28 weeks? Select all that apply.

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. Which action should the nurse implement first?

Abnormal FHR patterns can result in which condition?

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?

The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?

The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?