At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.
Which action should the nurse take first?

Start prescribed IV with lactated Ringer's.

Inform the anesthesia care provider.

Contact the client's obstetrician.

Ensure preoperative lab results are available.

Answer and Explanation

The Correct Answer is B

Choice B rationale

Informing the anesthesia care provider is the priority action. Ingesting coffee within a few hours before surgery can affect anesthesia management, and the anesthesia team needs to be aware of any potential complications.

Choice A rationale

Starting the IV is important but not the priority in this scenario. The anesthesia care provider needs to be informed first.

Choice C rationale

Contacting the obstetrician is also important but comes after informing the anesthesia care provider.

Choice D rationale

Ensuring preoperative lab results are available is essential, but the first step should be to inform the anesthesia care provider about the coffee intake.

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 A

Explanation

Choice A rationale

Assessing the fetal heart rate and client's contraction pattern is the highest priority when a large amount of bright red vaginal bleeding occurs. It is crucial to evaluate fetal well-being and the progression of labor to determine any immediate interventions needed to ensure the safety of both the mother and fetus.

Choice B rationale

Confirming Rh and Coombs status for Rho(D) immunoglobulin administration is important for Rh-negative mothers, but it is not the immediate priority in the presence of significant vaginal bleeding. Ensuring fetal and maternal stability takes precedence over Rh status confirmation.

Choice C rationale

Determining fetal position by performing Leopold maneuvers is not the highest priority when there is significant vaginal bleeding. While fetal position is relevant, immediate assessment of fetal heart rate and maternal contraction pattern is more critical for evaluating the urgency of the situation.

Choice D rationale

Performing a sterile vaginal examination to determine dilation is contraindicated in the presence of vaginal bleeding, as it can exacerbate the situation and lead to further complications. Immediate assessment of fetal well-being and maternal condition is more crucial before considering any internal examination. .

A. Obtain consent for the Hepatitis B vaccine. B. Collect a venous specimen for serum glucose level. C. Assess for the presence of the Moro reflex. D. Ensure that zidovudine is given within 6 hours after birth.

Correct Answer is D

Explanation

Choice A rationale

Obtaining consent for the Hepatitis B vaccine is a necessary step in the newborn's care, but it is not the immediate priority for a newborn exposed to HIV. The focus should be on preventing HIV transmission from mother to child.

Choice B rationale

Collecting a venous specimen for serum glucose level is important for assessing the newborn's metabolic status, but it does not directly address the immediate need to reduce the risk of HIV transmission.

Choice C rationale

Assessing for the presence of the Moro reflex is part of a routine newborn examination and is important for evaluating the neurological status of the newborn. However, it does not address the immediate priority of HIV prophylaxis.

Choice D rationale

Ensuring that zidovudine is given within 6 hours after birth is critical for reducing the risk of mother-to-child transmission of HIV. Early administration of antiretroviral medication is essential to prevent viral replication and transmission to the newborn.

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

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is caring for a newborn with suspected neonatal abstinence syndrome.The mother is currently taking methadone and is in a treatment program.Which intervention should the nurse implement prior to discharge?

During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.The nurse notes the client has 3+ bilateral, pitting, pedal edema.Which action should the nurse implement?

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth.Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

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?

The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.Which potential issue(s) place the client at risk? Select all that apply.

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug.How should the nurse respond?

A client who is scheduled for induction of labor receives a prescription for oxytocin 2 milliunits/min intravenously (IV). The IV bag contains oxytocin 20 units in lactated Ringer's 1 liter. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only)

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.
Which action should the nurse take first?