Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse
take first?
A. Turn the client onto her side.
The priority action when the fetal monitor tracing shows late decelerations after the client's membranes rupture is to turn the client onto her side. This position change helps relieve pressure on the vena cava and improves blood flow to the fetus.
B. Increase the client's IV fluid infusion rate.
Increasing the client's IV fluid infusion rate is not the first priority in this situation, as late decelerations are primarily related to uteroplacental insufficiency rather than maternal hydration status.
C. Administer oxygen to the client.
Administering oxygen to the client is important, but turning the client onto her side should be the first action to improve fetal oxygenation.
D. Palpate the client's uterus.
Palpating the client's uterus is not the first priority in the presence of late decelerations. The focus should be on relieving the compression on the vena cava and improving fetal oxygenation by changing the client's position.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternity Exam - Proctored Exam 2. Take the full exam now
Full Explanation
Choice A:The priority action when the fetal monitor tracing shows late decelerations after the client's membranes rupture is to turn the client onto her side. This position change helps relieve pressure on the vena cava and improves blood flow to the fetus.
Choice B: Increasing the client's IV fluid infusion rate is not the first priority in this situation, as late decelerations are primarily related to uteroplacental insufficiency rather than maternal hydration status.
Choice C: Administering oxygen to the client is important, but turning the client onto her side should be the first action to improve fetal oxygenation.
Choice D: Palpating the client's uterus is not the first priority in the presence of late
decelerations. The focus should be on relieving the compression on the vena cava and improving fetal oxygenation by changing the client's position.
Similar Questions
A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?
A. "It occurs during the first trimester and near the end of the pregnancy."
Urinary frequency is a common symptom during pregnancy, especially in the first trimester and near the end of the pregnancy. During the first trimester, it is mainly due to hormonal changes and increased blood flow to the pelvic area. In the later stages, it is caused by the growing uterus putting pressure on the bladder.
B. "It's a minor inconvenience, which you should ignore."
Dismissing the client's concern as a minor inconvenience is not appropriate and may disregard the client's experience.
C. "There is no way to predict how long it will last in each individual client."
While it is true that each individual client's experience may vary, it is important to provide the client with information regarding common patterns.
D. "In most cases, it only lasts until the 12th week, but it will continue if you have poor bladder tone."
Providing accurate information about the duration of urinary frequency is important. While it may last until the 12th week for many women, it does not continue throughout the entire pregnancy for most individuals, regardless of bladder tone.
Full Explanation
Choice A: Urinary frequency is a common symptom during pregnancy, especially in the first trimester and near the end of the pregnancy. During the first trimester, it is mainly due to
hormonal changes and increased blood flow to the pelvic area. In the later stages, it is caused by the growing uterus putting pressure on the bladder.
Choice B: Dismissing the client's concern as a minor inconvenience is not appropriate and may disregard the client's experience.
Choice C: While it is true that each individual client's experience may vary, it is important to provide the client with information regarding common patterns.
Choice D: Providing accurate information about the duration of urinary frequency is important. While it may last until the 12th week for many women, it does not continue throughout the entire pregnancy for most individuals, regardless of bladder tone.
A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?
A. "The child might develop encephalitis, a complication of rubella."
While rubella can lead to complications like encephalitis, this answer does not address the reason for isolation precautions for the newborn.
B. "Exposure to rubella will suppress the newborn's immune response."
While rubella can suppress the immune response in general, it does not explain the need for isolation of the newborn specifically.
C. "The newborn is at risk for developing a TORCH infection."
TORCH (Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes) infections are a group of infections that can be transmitted from mother to fetus during pregnancy. While rubella is part of the TORCH infections, this answer does not specifically address the reason for isolation of the newborn after delivery.
D. "The newborn might be actively shedding the virus."
Rubella, also known as German measles, is a contagious viral infection. Newborns born to mothers with rubella can be at risk because the virus can be transmitted to them during delivery. The newborn might be actively shedding the virus, which is why isolation precautions are necessary to prevent the spread of the infection to other vulnerable newborns or individuals.
Full Explanation
Choice A: While rubella can lead to complications like encephalitis, this answer does not address the reason for isolation precautions for the newborn.
Choice B: While rubella can suppress the immune response in general, it does not explain the need for isolation of the newborn specifically.
Choice C: TORCH (Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes) infections are a group of infections that can be transmitted from mother to fetus during pregnancy. While rubella is part of the TORCH infections, this answer does not specifically address the reason for isolation of the newborn after delivery.
Choice D: Rubella, also known as German measles, is a contagious viral infection. Newborns born to mothers with rubella can be at risk because the virus can be transmitted to them during delivery. The newborn might be actively shedding the virus, which is why isolation precautions are necessary to prevent the spread of the infection to other vulnerable newborns or individuals.
A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the
client that smoking places the client's newborn at risk for which of the following complications?
A. Type 1 diabetes mellitus
Smoking is not directly associated with the development of type 1 diabetes mellitus in the baby.
B. Hearing loss
While smoking during pregnancy can have various effects on the baby's health, hearing loss is not one of the common complications.
C. Congenital heart defects
Although smoking during pregnancy is associated with an increased risk of congenital heart defects, intrauterine growth restriction is a more likely complication based on the client's smoking history.
D. Intrauterine growth restriction
Smoking during pregnancy is associated with various adverse outcomes for both the mother and the baby. It can cause intrauterine growth restriction (IUGR), where the baby does not grow at the expected rate and has a lower birth weight. Smoking reduces blood flow to the placenta, which can affect the baby's growth and development.
Full Explanation
Choice A: Smoking is not directly associated with the development of type 1 diabetes mellitus in the baby.
Choice B: While smoking during pregnancy can have various effects on the baby's health, hearing loss is not one of the common complications.
Choice C: Although smoking during pregnancy is associated with an increased risk of congenital heart defects, intrauterine growth restriction is a more likely complication based on the client's smoking history.
Choice D: Smoking during pregnancy is associated with various adverse outcomes for both the mother and the baby. It can cause intrauterine growth restriction (IUGR), where the baby does not grow at the expected rate and has a lower birth weight. Smoking reduces blood flow to the placenta, which can affect the baby's growth and development.