NCLEX Exam Practice Question of the Week - 7/25/12

Elsevier NCLEX Exam Review

Question: Shortly after an amniotomy, the nurse determines that the fetal heart rate has decreased from 140 to 80 beats per minute. What is the priority nursing action?

1. Inspect the vagina
2. Administer oxygen
3. Notify the practitioner
4. Place in the knee-chest position

Answer: 1

Rationale:  Inspection seeks to identify the cause for the decreased fetal heart rate; the cord may have prolapsed. Administering oxygen may be done later, but it is not the priority. The practitioner should be notified after further assessment reveals more information. Placing the client in the knee-chest position is an intervention that can be implemented once it is determined that the umbilical cord is prolapsed; it relieves pressure on the cord, which increases the flow of oxygen and nutrients to the fetus.

Clinical Area: Childbearing and Women’s Health Nursing
Client Need: Reduction of Risk Potential
Cognitive Level: Application
Nursing Process: Evaluation

This week’s NCLEX exam practice question came from:

Nugent: Mosby's Review Questions for the NCLEX-RN Examination, 7th Edition, Chapter 6 (Comprehensive Exam), Page 504, Question 57

Check out other great NCLEX exam review resources from Elsevier!