Page 768 - Saunders Comprehensive Review For NCLEX-RN

Complete prolapse of cord. Membranes are intact. C, Cord presenting in front of the fetal
head may be seen in the vagina. D, Frank breech presentation with prolapsed cord.

Practice Questions

238. The nurse is performing an assessment on a client who has just been told that
a pregnancy test is positive. Which assessment finding indicates that the
client is at risk for preterm labor?
1. The client is a 35-year-old primigravida.
2. The client has a history of cardiac disease.
3. The client’s hemoglobin level is 13.5 g/dL (135 mmol/L).
4. The client is a 20-year-old primigravida of average weight and
height.
239. The nurse is monitoring a client who is in the active stage of labor. The nurse
documents that the client is experiencing labor dystocia. The nurse
determines that which risk factors in the client’s history placed her at risk for
this complication? Select all that apply.
1. Age 54 years

2. Body mass index of 28

3. Previous difficulty with fertility

4. Administration of oxytocin for induction
5. Potassium level of 3.6 mEq/L (3.6 mmol/L)

240. The nurse in a birthing room is monitoring a client with dysfunctional labor
for signs of fetal or maternal compromise. Which assessment finding should
alert the nurse to a compromise?
1. Maternal fatigue
2. Coordinated uterine contractions
3. Progressive changes in the cervix
4. Persistent nonreassuring fetal heart rate
241. The nurse in a labor room is preparing to care for a client with hypertonic
uterine contractions. The nurse is told that the client is experiencing
uncoordinated contractions that are erratic in their frequency, duration, and
intensity. What is the priority nursing action?
1. Provide pain relief measures.
2. Prepare the client for an amniotomy.
3. Promote ambulation every 30 minutes.
4. Monitor the oxytocin infusion closely.
242. The nurse is reviewing the primary health care provider’s (PHCP’s)
prescriptions for a client admitted for premature rupture of the membranes.
Gestational age of the fetus is determined to be 37 weeks. Which prescription
should the nurse question?
1. Monitor fetal heart rate continuously.
2. Monitor maternal vital signs frequently.

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