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The client is admitted to the hospital after her membranes rupture at 38 weeks gestation. A vaginal examination is done. The nurse determines that the client is 3 cm dilated, 40% effaced, and the fetal head is at -1 station. The external monitor snows that contractions are occurring every 4 minutes and lasting 70 seconds, and the nurse palpates the quality as strong. Her fasting blood glucose (FSBG) is 86 (4.8 mmol/L).

The client is transferred to the labor- delivery-recovery (LDR) suite. The client dilates quickly to 10 cm and feels a strong urge to push. The fetal heart rate is reassuring with a baseline of 145 and moderate variability. The nurse briefly reviews pushing techniques with her and her husband and notifies the obstetrician of the client's progress. After three cycles of open-glottis pushing, the baby's head is crowning. The head is born easily over an intact perineum. The infant weighs 9 lbs. 9 oz (4.34 kgs) and has an Apgar of 7 at 1 minute, then 9 at 5 minutes.

client is 3 cm dilated, 40% effaced, and the fetal head is at -1 station

contractions are occurring every 4 minutes and lasting 70 seconds

fasting blood glucose (FSBG) is 86 (4.8 mmol/L)

client dilates quickly to 10 cm and feels a strong urge to push

fetal heart rate is reassuring with a baseline of 145 and moderate variability

Apgar of 7 at 1 minute, then 9 at 5 minutes

After three cycles of open-glottis pushing, the baby's head is crowning

infant weighs 9 lbs. 9 oz

membranes rupture at 38 weeks gestation

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

This blood glucose level is within the normal range, indicating that the client’s blood sugar is well-controlled at this point.

The client is 3 cm dilated, 40% effaced, with contractions every 4 minutes lasting 70 seconds and strong in quality. These are signs of active labor progressing appropriately.

The fetal heart rate is reassuring with a baseline of 145 beats per minute and moderate variability. This indicates good fetal well-being and adequate oxygenation.

The client quickly dilates to 10 cm and experiences a strong urge to push, suggesting efficient progress through labor.

The baby is born with an intact perineum, weighs 9 lbs. 9 oz (4.34 kg), and has excellent Apgar scores of 7 at 1 minute and 9 at 5 minutes. These scores indicate that the infant is in good condition and adapting well to extrauterine life.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Family history of schizophrenia is relevant but not immediately critical.

B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.

C. Social anxiety symptoms are important but not as critical as addressing suicide risk.

D. Disorientation needs assessment but is not as urgent as managing suicide risk.

A. Call for an assistant. B. Close the room door. C. Finish the procedure. D. Respond to the code.

Correct Answer is A

Explanation

A. The nurse should call for an assistant to take over the tracheostomy care so the nurse can respond to the code blue.

B. Closing the room door is not an appropriate response in this emergency situation.

C. Finishing the procedure would delay the nurse’s response to the code blue, which is urgent.

D. Responding to the code is crucial, but the nurse should ensure the client's tracheostomy care is continued by calling for assistance first.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is B

Explanation

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Correct Answer is A

Explanation

A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?

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A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important for the nurse to implement?

The nurse is providing dietary education to a client in end stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the client's daily diet?