Exhibits

The nurse reviews the client data.

Complete the diagram by dragging from the choices area to specify what is occurring with the fetus, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess progress.

Answer and Explanation

The Correct Answer is []

Rationale for correct choices:

Cord compression: The decelerations in fetal heart rate (FHR) are more likely caused by cord compression, which can result in transient reductions in oxygen supply. The decelerations, although brief, point to this as the most probable cause.
Change position (side to side, knee-chest): Changing the maternal position can help relieve pressure on the umbilical cord, improving blood flow and oxygenation to the fetus. Positions like side-to-side or knee-chest can be especially effective in relieving cord compression.
Oxygen at 10 L via nonrebreather face mask: Administering oxygen to the mother helps increase oxygen supply to the fetus. This can be particularly helpful in cases of cord compression where fetal oxygenation may be compromised.
Length of time FHR takes to return to baseline: Monitoring the length of time for the FHR to return to baseline after decelerations helps assess the severity of fetal distress. Prolonged or persistent decelerations may indicate worsening fetal compromise.
Frequency of decelerations: The nurse should monitor how often the decelerations occur. Frequent or persistent decelerations may require more aggressive interventions and provide insights into the underlying cause (e.g., cord compression).

Rationale for incorrect choices:

Prepare for operative delivery: The priority is addressing the possible cord compression through maternal positioning and oxygenation. Operative delivery is not necessary unless the situation does not improve or worsens significantly.
Assess maternal blood glucose: While maternal blood glucose may impact fetal well-being, the primary issue in this case appears to be cord compression, which requires positional changes and oxygen rather than glucose management.
Decrease IV rate: There is no indication that the IV rate is contributing to the FHR decelerations. In fact, maintaining hydration and ensuring adequate blood volume is important, especially in labor, so decreasing the IV rate is not appropriate.

Placenta previa: Placenta previa would present with vaginal bleeding and is not suggested by the current symptoms. FHR decelerations are more consistent with cord compression.
Fetal reaction to pain medication: There is no evidence of maternal pain medication administration, and the decelerations appear to be caused by cord compression, not medication effects.
Head compression: Head compression typically causes quick, variable decelerations, while these appear more gradual and are consistent with cord compression.
Maternal blood pressure: The maternal blood pressure is stable and does not seem to be causing the FHR decelerations, which are likely due to cord compression.
Cervical dilation and effacement: Cervical changes are important for labor progress but do not affect the FHR decelerations, which are related to cord compression.
Strength of contractions: The strength of contractions is not the cause of the decelerations. Cord compression is the primary issue, not uterine contractions.

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Correct Answer is ["A","B","E","F","I"]

Explanation

A. Notify primary healthcare provider: The client is showing signs of postpartum hemorrhage, including a boggy fundus, significant blood loss, and a drop in blood pressure. Immediate communication with the healthcare provider is essential for further assessment and management.

B. Weigh all bloody materials: Weighing the pads and other bloody materials will provide a more accurate measure of the blood loss, which is crucial in assessing excessive bleeding. This will help guide further interventions and determine the severity of the hemorrhage.

C. Administer 2 units of packed red blood cells (PRBC): While the client’s hemoglobin and hematocrit are slightly low (11g/dL), immediate blood transfusion is not necessary unless the client shows signs of severe hypovolemia or shock. The focus should first be on stopping the hemorrhage.

D. Increase the IV fluid to maximum rate: The client’s IV fluid is already infusing at a rate of 125 mL/hr, which is appropriate for maintaining hydration. Increasing the IV rate may be helpful if the client shows signs of significant blood loss or shock.

E. Count saturated pads per hour: Monitoring the number of saturated pads per hour is critical to assessing the rate of bleeding. Excessive bleeding will help determine if interventions, such as administering medications or increasing fluids, are required to manage the hemorrhage effectively.

F. Insert straight catheter: The fundus is rotated to the right, which could indicate a full bladder, a common cause of uterine displacement and ineffective contractions. Inserting a straight catheter to empty the bladder can help reposition the uterus, improving contraction and reducing the risk of hemorrhage.

G. Alert the emergency response team: While the situation is concerning, the initial interventions should focus on managing the bleeding with appropriate steps like massaging the fundus and notifying the healthcare provider. Alerting the emergency response team may not be immediately necessary.

H. Administer 0.2 mg methylergonovine IM: Methylergonovine is used to manage uterine atony, but it is typically used when other interventions, like fundal massage, are ineffective. It is not the first intervention to try and should be used cautiously. The priority is to assess and stabilize the client.

I. Massage fundus until firm: The fundus is boggy, indicating uterine atony, which is a leading cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contraction and is the first-line intervention for uterine atony.

A. Inform the couple that this is not an inherited disorder. B. Tell the couple to discuss this issue with the obstetrician. C. Encourage the couple to consider adopting a baby. D. Refer the couple to a genetic counselor or geneticist.

Correct Answer is D

Explanation

A. Inform the couple that this is not an inherited disorder: Cleft lip and palate can have a genetic component, so telling the couple it is not inherited would be misleading. While environmental factors can also contribute, the genetic link should not be dismissed.
B. Tell the couple to discuss this issue with the obstetrician: While the obstetrician can provide guidance, a genetic counselor or geneticist is more specialized in addressing hereditary concerns and can offer more precise advice on the potential risks and genetic implications.
C. Encourage the couple to consider adopting a baby: While adoption is a valid option for many, it is not the most appropriate response to the couple's concern about the potential genetic risk of cleft lip and palate. This decision should be informed by genetic counseling.
D. Refer the couple to a genetic counselor or geneticist: A genetic counselor can assess the family history and provide the couple with accurate information on the risks of having a child with a cleft lip and palate, helping them make an informed decision based on genetic factors.

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Exhibits The nurse reviews the client data. Complete the diagram by dragging from the choices area to specify what is occurring with the fetus, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess progress.

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Naxlex Comprehensive Predictor Exams

Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

Correct Answer is ["A","B","E","F","I"]

Explanation

A young married couple asks the nurse at a community outreach clinic for guidance about having children because the wife was born with a cleft lip and palate, and the husband has an uncle with a cleft lip. Which action should the nurse take?

Correct Answer is D

Explanation

Exhibits Which education by the nurse will help resolve the issue for the client? Select all that apply.

A premenopausal client with uterine leiomyomas (fibroids) reports to the clinic nurse that her menstrual bleeding has increased in volume and duration. Which assessment should the nurse perform first?

The healthcare provider prescribed triazolam 500 mcg for a client with insomnia. The pharmacy supplies triazolam in 0.25 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.)

The nurse is planning discharge teaching for 4 mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?

Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Exhibits The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet. Select the findings that will help the nurse determine which is causing the client's symptoms.

Exhibits

The nurse reviews the client data.

Complete the diagram by dragging from the choices area to specify what is occurring with the fetus, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess progress.