Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center.She is lying supine on a backboard, is awake, and denies any complaints.
Her blood pressure is 80/50 mmHg and her heart rate is 130 beats/minute.
Which action should the nurse implement first?

Infuse 1,000 mL normal saline using a large bore IV.

Obtain a blood sample for a complete blood count.

Tilt the backboard sideways to displace the uterus laterally.

Palpate the abdomen for contractions.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Infusing 1,000 mL normal saline using a large bore IV is a good response to increase the client's blood volume and improve blood pressure, but it should not be the first action. The immediate priority is to relieve the compression of the inferior vena cava caused by the gravid uterus, which is decreasing blood return to the heart and causing hypotension.

Choice B rationale

Obtaining a blood sample for a complete blood count is important for assessing the client's overall health and identifying any possible complications, but it does not address the immediate life-threatening issue of hypotension caused by the gravid uterus compressing the inferior vena cava.

Choice C rationale

Tilting the backboard sideways to displace the uterus laterally is the correct first action. This maneuver helps to relieve the compression of the inferior vena cava by the gravid uterus, thereby improving blood return to the heart, increasing cardiac output, and normalizing blood pressure.

Choice D rationale

Palpating the abdomen for contractions is important to assess for potential labor or uterine irritability, but it does not address the immediate need to relieve the compression of the inferior vena cava causing hypotension.

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Correct Answer is D

Explanation

Choice A rationale

Yogurt is a good source of calcium and protein but is not particularly high in folic acid. It is beneficial for overall health but not the best option for increasing folic acid intake.

Choice B rationale

Collard greens are high in folic acid, but since the client does not like green leafy vegetables, this option is not suitable for her.

Choice C rationale

Whole milk provides vitamin D and calcium, but it is not a significant source of folic acid. It would not effectively help the client meet her increased folic acid needs.

Choice D rationale

Strawberries are a good source of folic acid and can be a suitable option for the client to increase her intake without consuming green leafy vegetables or soy products. .

A. Blood pressure of 170/98 mm Hg B. Pain rating of 5 out of 10 with each contraction C. Variable decelerations lasting 20 seconds D. Fetal heart rate of 142 beats/minute with accelerations E. Deep tendon reflexes absent F. Temperature of 98.6° F (37° C)

Correct Answer is ["A","C","E"]

Explanation

Choice A rationale: A blood pressure of 170/98 mm Hg is significantly elevated and concerning during pregnancy. This may indicate preeclampsia, which requires immediate intervention to prevent complications for both the mother and the fetus.

Choice B rationale: A pain rating of 5 out of 10 with each contraction is common during labor and does not necessarily require intervention unless the pain is unmanageable or the client requests additional pain relief measures.

Choice C rationale: Variable decelerations lasting 20 seconds can indicate cord compression or other issues affecting fetal oxygenation. Continuous monitoring and possible interventions are required to ensure fetal well-being.

Choice D rationale: A fetal heart rate of 142 beats/minute with accelerations is a reassuring sign of fetal well-being. No immediate intervention is needed for this finding.

Choice E rationale: Absent deep tendon reflexes are a concerning finding, especially with the administration of magnesium sulfate. This can indicate magnesium toxicity, which requires prompt intervention to adjust the medication dosage and prevent adverse effects.

Choice F rationale: A temperature of 98.6° F (37° C) is within normal limits and does not require intervention.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is caring for a 34-year-old female client in the labor and delivery unit. Exhibits The nurse reviews the findings for the client. Which findings are concerning and require intervention? Select All That Apply)

Correct Answer is ["A","C","E"]

Explanation

When reading the obstetrical history of a client who is currently at 36 weeks gestation, the nurse notes that she has had one full-term infant, one premature infant born at 32 weeks gestation that survived, and one miscarriage.Which is this client's gravidity?

A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.The client reports no pain and normal laboratory results.Which action should the nurse implement first?

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 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?

A client at 40 weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive.Which action(s) should the nurse plan to perform? Select all that apply.

The nurse reviews the assessment findings along with the healthcare provider's prescriptions.Which immediate intervention(s) would the nurse initiate? Select all that apply.

The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.