The practical nurse (PN) is monitoring a client who was admitted for induction of labor. As the client's labor progresses to the second stage, the fetal heart rate falls to 100 beats/minute following each contraction.
Which intervention should the PN implement first?

Administer oxygen at 10 L/face mask.

Discontinue oxytocin infusion.

Observe perineum for cord prolapse.

Reposition the client laterally.

Answer and Explanation

The Correct Answer is D

Fetal heart rate (FHR) is one of the essential indicators of fetal well-being during labor. A fall in FHR following each contraction is known as recurrent deceleration and can be an indication of fetal distress. In this case, the PN should first reposition the client laterally, as this may help to alleviate compression of the umbilical cord and improve fetal oxygenation.
A.   Administering oxygen at 10 L/face mask may be necessary, but it is not the first intervention to be implemented in this scenario.
B.   Discontinuing oxytocin infusion may be necessary, but it is not the first intervention to be implemented in this scenario.
C.   Observing perineum for cord prolapse is not necessary in this scenario.

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Correct Answer is D

Explanation

Gestational diabetes mellitus (GDM) is a type of diabetes that occurs during pregnancy. If euglycemia, or normal blood glucose levels, is not maintained during pregnancy, the fetus can be at risk for a number of complications. The greatest risk to the fetus in this situation is the development of a macrosomic newborn, or a newborn that is significantly larger than average. This occurs because the excess glucose in the mother's bloodstream is passed on to the fetus, leading to excessive fetal growth.

Macrosomia can lead to complications during delivery, such as shoulder dystocia, and can increase the risk of injury to both the mother and the baby. While low birth weight and preterm birth are also potential complications of GDM, macrosomia is considered the greatest risk to the fetus if euglycemia is not maintained. Cleft palate is not typically associated with GDM.

A. Encourage voiding. B. Monitor vital signs. C. Notify healthcare provider. D. Inspect the perineal pad.

Correct Answer is A

Explanation

If the practical nurse (PN) is caring for a client who delivered 6 hours ago and assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus, the PN should encourage the client to void. A full bladder can displace the uterus and prevent it from contracting properly, leading to a boggy uterus. Encouraging the client to void can help empty the bladder and allow the uterus to contract and return to its normal position. The other actions listed may also be appropriate in some situations, but encouraging voiding is the most appropriate action in this situation.

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The practical nurse (PN) is monitoring a client who was admitted for induction of labor. As the client's labor progresses to the second stage, the fetal heart rate falls to 100 beats/minute following each contraction. Which intervention should the PN implement first?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client who has been diagnosed with gestational diabetes mellitus. Which complication should the PN recognize as the greatest risk to the fetus if euglycemia is not maintained?

Correct Answer is D

Explanation

The practical nurse (PN) is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the PN take?

Correct Answer is A

Explanation

A client who is a primigravida at 40 weeks gestation is contracting every 2 minutes and her cervix is 9 cm dilated and 100% eﬀaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the practical nurse (PN) implement?

The practical nurse (PN) is assigned to assist in the care of a laboring client at 42-weeks gestation. While providing perineal care, the PN observes the umbilical cord protruding from the vagina. Which action should the PN take?

A mother calls the clinic to report that her child has just swallowed "poison" and is vomiting. In preparing to instruct the mother about the necessary action to take, which substance should the practical nurse (PN) consider to be the least traumatic to the esophagus when the child vomits?

Epidural anesthesia is initiated for a primigravida at 40 weeks gestation who is in active labor. Which assessment has the greatest priority for the practical nurse to monitor during the administration of epidural anesthesia?

A 6-year-old female client who was recently diagnosed with type 1 diabetes mellitus (DM) comes to the clinic with anorexia, drowsiness, and polydipsia. Her parents report frequent urination and bedwetting episodes almost nightly. Which action should the practical nurse (PN) take?

A primigravida who is at 10-weeks gestation is hospitalized on the antepartum unit for pyelonephritis. The client tells the practical nurse (PN) that she has had several episodes of nausea. When reviewing her lunch menu, which food should the PN discourage her from choosing?

An older female client is admited to the orthopedic unit following surgical repair of a fractured hip. On the second postoperative day, the client becomes confused and repeatedly asks the practical nurse (PN) where she is. Which information should the PN obtain before reporting to the charge nurse?

The practical nurse (PN) is monitoring a client who was admitted for induction of labor. As the client's labor progresses to the second stage, the fetal heart rate falls to 100 beats/minute following each contraction.
Which intervention should the PN implement first?