Vaginal prostaglandin gel is used to induce labor for a woman who is at 42-weeks gestation.

Thirty minutes after insertion of the gel, she reports feelings of vaginal warmth and is experiencing 90-second contractions with fetal heart rate decelerations.

Which action should the nurse implement first?

Turn to a side-lying position.

Notify the healthcare provider.

Increase the IV infusion rate.

Assess the maternal vital signs.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Uterine hyperstimulation, characterized by contractions that are too frequent or last too long, can cause fetal compromise. Turning the woman to a side-lying position is the first intervention because it can improve placental blood flow by relieving compression on the vena cava. This enhances oxygen transfer to the fetus and may reduce the frequency and duration of contractions.

Choice B rationale

While notifying the healthcare provider is crucial, it is a subsequent step after initial interventions have been taken to stabilize the client and fetus. The nurse must first implement immediate actions to address the fetal distress and uterine hyperstimulation. This is an urgent situation where every second counts for fetal well-being.

Choice C rationale

Increasing the IV infusion rate, particularly if a tocolytic medication is being administered, might be a later intervention. However, the initial and safest action is to change the maternal position. Without knowing the full context of IV medications, this choice is not the first or most immediate priority.

Choice D rationale

Assessing the maternal vital signs is important, but the most immediate threat is to fetal oxygenation due to uterine hyperstimulation. The fetal heart rate decelerations are the most urgent finding. Therefore, the first action must be to improve fetal oxygenation by changing maternal position.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Playing "peek-a-boo" is a normal developmental milestone for a 6-month-old infant. This activity demonstrates object permanence, which is the understanding that objects continue to exist even when they cannot be seen, heard, or touched. This is an expected cognitive skill for this age.

Choice B rationale

Turning its head to locate sound is an appropriate developmental milestone for a 6-month-old infant. This response indicates intact hearing and developing auditory localization skills, which is the ability to determine the source of a sound. This is a normal and expected reflex.

Choice C rationale

The startle (Moro) reflex is a primitive reflex that should disappear by around 3 to 4 months of age. Its persistence beyond this time may indicate a neurological problem, such as a cerebral palsy or a central nervous system lesion. Therefore, a 6-month-old infant demonstrating this reflex requires further evaluation.

Choice D rationale

Doubling its birth weight by 5 to 6 months of age is a normal and expected physical growth milestone for an infant. This indicates adequate nutrition and healthy development. The average birth weight is approximately 7 to 8 pounds, and at 6 months, an infant should weigh about 14 to 16 pounds.

A. The client is experiencing an allergic reaction; the nurse should administer epinephrine immediately. B. The client has developed a urinary tract infection; the nurse should collect a urine sample for culture and sensitivity. C. The client is presenting with signs of preeclampsia; the nurse should monitor for seizure activity and administer prescribed medications. D. The client is experiencing a hypertensive crisis; the nurse should prepare for immediate surgery.

Correct Answer is C

Explanation

Choice A rationale

The client's symptoms, including severe headache, nausea, right-sided upper abdominal pain, and hyperreflexia (4+ DTRs), are classic indicators of severe preeclampsia, not an allergic reaction. An allergic reaction typically involves hives, itching, and respiratory distress. Administering epinephrine is an inappropriate intervention and would likely worsen the client's condition.

Choice B rationale

A urinary tract infection (UTI) typically presents with symptoms such as dysuria, frequency, and suprapubic pain. While a headache and nausea can be systemic symptoms of an infection, they do not explain the hyperreflexia or the right-sided upper abdominal pain. A UTI is a less likely diagnosis given the constellation of symptoms.

Choice C rationale

The symptoms presented, including a severe headache, nausea, right-sided upper abdominal pain (suggesting liver involvement), and hyperreflexia, are the hallmarks of severe preeclampsia. The priority intervention is to monitor for seizure activity and administer prescribed medications, such as magnesium sulfate, to prevent the progression to eclampsia, which is a life-threatening complication.

Choice D rationale

While the client is experiencing hypertension, the constellation of symptoms points to preeclampsia, a specific condition, rather than a general hypertensive crisis. Immediate surgery is not the first intervention. The priority is to stabilize the client and prevent a seizure while preparing for delivery, which is the definitive treatment.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Correct Answer is C

Explanation

What is the most likely cause of the client's symptoms, and what is the nurse's priority intervention?

Correct Answer is C

Explanation

When obtaining an adolescent's health history, which intervention is most important for the nurse to implement?

A school nurse is preparing a seminar to address the concerns of pregnant adolescents. Which information is most important for the nurse to include in the program?

The nurse is assessing the neurological system of a 1-month-old infant. During the exam, the infant demonstrates an absence of the startle (Moro) reflex. Which intervention should the nurse implement first?

The mother of a 4-year-old boy who has been hospitalized multiple times asks the nurse how she can help her other children who are asking about their brother. To help the siblings cope with their brother's illness, which suggestion is best for the nurse to provide this mother?

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

Exhibits 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.

A nurse is planning to administer betamethasone to a gravid client. Which client is most likely to receive this prescription?

The nurse reviews the client's history and physical to determine the cause of the client's symptoms. Highlight the information from the history and physical that requires further evaluation.