The nurse notifies the HCP after feeling a pulsating mass during the v

Maternal NCLEX

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Question 1 of 5.

The nurse notifies the HCP after feeling a pulsating mass during the vaginal examination of a newly admitted full-term pregnant client. Which HCP order should the nurse question?

A. Prepare for possible cesarean section.

B. Place the client in a knee-chest position.

C. Initiate a low-dose oxytocin IV infusion.

D. Give terbutaline 0.25 mg subcutaneously.

Explanation: The nurse should question the administration of oxytocin (Pitocin). Oxytocin is used for stimulating contraction of the uterus. Uterine contractions can cause further umbilical cord compression. The pulsating mass indicates umbilical cord prolapse, which is a medical emergency. If vaginal birth is not imminent, a cesarean section is preferred in order to prevent hypoxic acidosis. Placing the client in a knee-chest position relieves pressure on the umbilical cord. Terbutaline (Brethine) is a tocolytic agent used to reduce contractions.

Question 2 of 5.

The nurse correctly explains that the bleeding is the result of sloughing of which structure?

A. Endometrium

B. Myometrium

C. Epimetrium

D. None of the above

Explanation: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.

Question 3 of 5.

On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?

A. 5 months

B. 6 months

C. 7 months

D. 8 months

Explanation: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.

Question 4 of 5.

The nurse correctly assists the client into which position?

A. Lithotomy

B. Prone

C. Sims'

D. Trendelenburg's

Explanation: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.

Question 5 of 5.

Which response by the nurse is most accurate?

A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.

B. Hepatitis B surface antigen (HBsAg) test can detect this defect.

C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.

D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.

Explanation: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.