Which action is most important for the nurse to implement?

Increase IV infusion rate.

Assess the vital signs.

Massage the fundus.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Increasing IV infusion rate can exacerbate fluid overload and hypertension, potentially worsening the patient's condition. Monitoring fluid status and adjusting infusions cautiously is critical to avoid iatrogenic complications.

Choice B rationale

Assessing vital signs helps detect early signs of complications such as hypovolemia, infection, or abnormal bleeding, facilitating timely intervention to prevent further deterioration.

Choice C rationale

Massaging the fundus promotes uterine contraction, reducing the risk of postpartum hemorrhage. Effective fundal massage can control bleeding and stabilize the patient following childbirth.

Choice D rationale

Notifying the healthcare provider ensures prompt communication of any changes in the patient's condition, enabling timely medical intervention and potentially preventing adverse outcomes.

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Correct Answer is D

Explanation

Choice A rationale

Assessing pain intensity with contraction is not the priority when preeclampsia is suspected. The client's headache, hypertension, and edema indicate a need to evaluate for more specific signs of preeclampsia.

Choice B rationale

Fetal heart rate assessment is important, but evaluating maternal status is more urgent when preeclampsia symptoms are present. Monitoring maternal indicators helps determine the severity of preeclampsia.

Choice C rationale

Checking temperature, pulse, and respirations is part of routine assessment, but it does not provide specific information related to preeclampsia. Other assessments are more relevant for the client's condition.

Choice D rationale

Assessing deep tendon reflexes and clonus helps identify severe preeclampsia and potential for eclampsia. Hyperreflexia and clonus are signs of central nervous system irritability, requiring immediate attention and intervention.

A. Passive immunity in the first months of life provides protection in newborns. B. Infants can receive antiinfectants that have not developed resistance to microbes. C. Active immunity in newborns is developed fully in the first month of life. D. Neutrophils may be immature in protecting neonates from the risk for infection.

Correct Answer is A

Explanation

Choice A rationale

Passive immunity provided by maternal antibodies crossing the placenta and through breast milk protects newborns in the first months of life, offering initial defense against communicable diseases.

Choice B rationale

Antiinfectants effectiveness against microbes does not apply; newborns rely on passive immunity as their adaptive immune system matures, not unresistant antiinfectants.

Choice C rationale

Active immunity develops over several months to years in newborns, as their immune system gradually encounters pathogens and develops specific responses.

Choice D rationale

While neutrophils are part of the innate immune system, they may still be immature and insufficient in preventing infections in neonates without maternal antibody support.

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Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?

Correct Answer is D

Explanation

A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given. Which physiological mechanism should the nurse use when responding to the mother’s concerns?

Correct Answer is A

Explanation

Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

Which action is most important for the nurse to implement?

The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?

One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell (WBC) count is 15,000/mm³ (15 x 10⁹/L). Which action should the nurse take first?

A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)

A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?

The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)