NSG 4800/ NSG4800 Comprehensive Exam V2 – Professional Nursing Practice 2026/2027 | Galen | Latest Questions & Verified Answers

NSG 4800/ NSG4800 Comprehensive Exam V2 – Professional Nursing Practice 2026/2027 | Galen | Latest Questions & Verified Answers The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? A .temperature of 100.4°F (38°C) B. An increase in the pulse rate from 88 to 102 beats/minute C. A blood pressure changes from 130/88 to 124/80 mm Hg D. An increase in the respiratory rate from 18 to 22 breaths/minute B, During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal. The nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which statement would be most appropriate for the nurse to include in the home care instructions for this client? "Apply ice to the site to prevent swelling." "Clean the site with alcohol 3 times daily." "Apply a warm, damp washcloth if discomfort occurs." "Avoid showering or taking baths until seen by the health care provider in 1 week." 3, Cryotherapy involves the local application of liquid nitrogen to the lesion; this causes cell death and tissue destruction. Tissue freezing is followed in 1 to 2 days by hemorrhagic blister formation; therefore, ice is not applied to the site. The application of a warm, damp washcloth intermittently to the site will provide relief of any discomfort. The nurse instructs the client to clean the site with the prescribed solution to prevent secondary infection. A topical antibiotic also may be prescribed. Alcohol would cause irritation to the skin. There is no reason for the client to avoid showering or bathing. The registered nurse is caring for the following clients. It would be a priority for the nurse to initiate a multidisciplinary conference for the client who is A.12 years old with Autism who is starting a new school and recently had a URI (upper respiratory tract infection) B.39 years old, has type 2 Diabetes Mellitus, is homeless and had a recent Hemoglobin A1c of 13% C.52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and is employed as a mail carrier D.79 years old, has bipolar and schizophrenia, lives alone and reports hearing non threatening voices. B A client with uncontrolled Diabetes Mellitus would require the greatest number of disciplines (multidisciplinary) to manage their care i.e. Medicine, Nursing, Social Work, Nutritionist; the other choices do not require as many providers of care to meet their needs. A client is scheduled to begin therapy with carbamazepine. The nurse should assess the results of which test(s) before administering the first dose of this medication to the client? Liver function tests Renal function tests Pancreatic enzyme studies Complete blood cell count D. Carbamazepine may be used to treat a seizure disorder. It can cause leukopenia, anemia, thrombocytopenia, and, very rarely, fatal aplastic anemia. To reduce the risk of serious hematological effects, a complete blood cell count should be done before treatment and periodically thereafter. This medication should be avoided in clients with preexisting hematological abnormalities. The client also is told to report the occurrence of fever, sore throat, pallor, weakness, infection, easy bruising, and petechiae. The results of the remaining tests listed in the options are not associated with the use of this medication. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? An ampule of 50% dextrose NPH insulin subcutaneously IV fluids containing dextrose Phenytoin for the prevention of seizures C. Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA. A client is being discharged from the emergency department after an evaluation for a concussion. The nurse reinforces teaching regarding follow-up should the client develop complications. Which of the following complications, if listed by the client, would require further instruction? 1. Vomiting 2. Minor headache 3. Difficulty speaking 4.Difficulty awakening 2; all others responses would indicate IICP and needs to go to the ER The patient sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock? A. cardiogenic B. hypovolemic C. neurogenic D. anaphylactic B. A fractured femur, especially an open fracture, can cause much soft tissue damage and lead to significant blood loss. Hypovolemic shock can develop. Cardiogenic shock occurs when cardiac output is decreased as a result of ineffective pumping. Neurogenic shock occurs as a result of an impaired autonomic nervous system function. Anaphylactic shock is the result of an allergic reaction. The registered nurse has received a report on four clients. The nurse should first assess the client who has: A.Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 89% B.Parkinson's Disease and is demanding to leave the hospital against medical advice (AMA) C.been admitted with suspected Guillian Barre Syndrome and has begun plasmapheresis therapy D.Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) C. The client admitted with Guillain-Barre' Syndrome should be assessed first because of the possibility of rapid progression of this illness and neuromuscular respiratory failure; clients with COPD are likely to have pulse oximetry readings of 90% related to chronic hypoxia; this client along with the other two choices are important, but not the priority. A client with chronic renal failure is receiving hemodialysis three times a week. What should the nurse do to protect the fistula? A. Take the blood pressure in the arm with the fistula. B. Report the loss of a thrill or bruit on the arm with the fistula. C. Maintain a pressure dressing on the shunt. D. Start a second IV in the arm with the fistula. B. The nurse must always auscultate for a bruit and palpate for a thrill in the arm with the fistula and promptly report the absence of either a thrill or bruit to the health care provider as it indicates an occlusion. The client should not have a pressure dressing on the shunt and should avoid wearing tight clothing or carrying heavy items such as a purse over the area of the shunt to avoid restricting blood flow in the shunt. No procedures such as IV access, blood pressure measurements, or blood draws are done on an arm with a fistula as they could damage the fistula. The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. Restating Listening Asking the client "Why?" Maintaining neutral responses Providing acknowledgment and feedback Giving advice and approval or disapproval 1, 2, 4, 5. Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication. Which client should the emergency department triage nurse classify as emergent? A client with a displaced fracture who is crying A client with a simple laceration and soft tissue injury A client with crushing substernal pain who is short of breath A client with a temperature of 101°F (38.3°C) with a productive cough 3, A triage method commonly used in the emergency department consists of 3 categories: emergent, urgent, and nonurgent. The emergent category implies that a condition exists that poses an immediate threat to life or limb. An example of a client who fits into this category is the client experiencing crushing substernal pain who is short of breath. The urgent category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. The client with a displaced fracture who is crying and the client with a temperature of 101°F (38.3°C) and a productive cough would fit into this category. The nonurgent category indicates that the client can generally tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple laceration and soft tissue injury would fit into this category. A patient is being evaluated for hypothyroidism. To plan care, the nurse should ask the client about which sign or symptom? 1) corneal abrasion 2) weight loss 3) diarrhea 4) fatigue Fatigue Rationale: A major problem for the person with hypothyroidism is fatigue. Other signs and symptoms include lethargy, personality changes, generalized edema, impaired memory, slowed speech, cold intolerance, dry skin, muscle weakness, constipation, weight gain (10-30lbs), heavy menstrual periods (menorrhagia), and hair loss. You are caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin- resistant S. aureus (VRSA). Which nursing action can you delegate to an LPN/LVN? A. Planning ways to improve the client's oral protein intake. B. Teaching the client about home care of the leg ulcer. C. Obtaining would cultures during dressing changes. D. Assessing the risk for further skin breakdown. C. The other options can only be done by the RN. A patient is scheduled to have a radiological examination of the large intestine and a barium enema is prescribed by the physician. What teaching will the nurse provide? Select all that apply. Tell the nurse if you have a sensation of flatulence after the exam. Instruct the patient that stool may be chalky for up to 72 hours after the exam. Instruct the patient to drink plenty of fluids and take laxatives as prescribed after the exam. Do not eat or drink for 24hours after the exam. 1,2,3 Rationale: Fluids should be promoted after an exam requiring a barium enema to avoid intestinal obstruction. Appropriate patient teaching for a lower GI series includes instructing the patient to use laxatives as prescribed by the physician and educating the patient to expect stools to be chalky white for 24 to 72 hours after the exam. Flatulence is a sign of the return to normal bowel function. Endoscopic retrograde cholangiopancreatography (ERCP) is used to identify the location of obstruction in which organs? Select all that apply. Liver. Gallbladder. Ilieum. Bile ducts. Pancreas. 1,2,4,5 Rationale: ERCP is a radiographic examination of the liver, gallbladder, bile ducts, and pancreas to treat problems of the bile and pancreatic ducts. A 74-year-old male complains of new-onset of headaches. The headaches are described as bilateral frontal and most severe when arises in the morning; and when coughing. The history is consistent with headaches caused by: tension-type headache cluster-type headache increased intracranial pressure migraine with aura 3 secondary headaches caused by IICP- awakening the brain swelling is the worst. A patient is diagnosed with oral candidiasis and the physician prescribes nystatin (Mycostatin) oral suspension for treatment. What instruction should the nurse include in the patient teaching? Do not take this medication if your mouth stops hurting. Swish the medication around in your mouth for several minutes before swallowing. Take this medication once a day after breakfast. Spit the medication out after you use it for a few seconds. #2 Rationale: The patient is instructed to swish and swallow the oral suspension of nystatin. The oral suspension should be used four times a day for 7 to 10 days for fungal infections in the oral cavity. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? Cranial nerve I, olfactory Cranial nerve IV, trochlear Cranial nerve III, oculomotor Cranial nerve VII, facial nerve 4, An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal. The nurse should expect to find elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) is a patient with what diagnosis? Aspiration pneumonia. Viral hepatitis. Esophageal varices. Clostridium difficile. #2 Rationale: AST and ALT are enzymes found in the liver and these enzymes are elevated in most liver disorders such as viral hepatitis and cirrhosis of the liver. The nurse is admitting a client with major depression. It would be a priority for the nurse to A. Determine if the client was voluntarily admitted B. Ask the client if suicide has been contemplated C. Have the client's possessions searched for sharps D.Administer to the client the prescribed antidepressant B Asking about suicidal thoughts or plans is a priority when caring for the depressed client. The person may not volunteer this information without being asked. If the client answers yes, further assessment is required, and suicide precautions initiated A parent brings her 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? (Scroll for Answer) Varicella, hepatitis B vaccine (HepB) Diphtheria, tetanus, acellular pertussis (DTaP); measles, mumps, rubella (MMR); inactivated poliovirus vaccine (IPV) MMR, Haemophilus influenza type b (Hib), DTaP DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine (RV) 4. DTaP, Hib, IPV, PCV, and RV are administered at 4 months of age. DTaP is administered at 2, 4, and 6 months of age; at 15 to 18 months of age; and at 4 to 6 years of age. Hib is administered at 2, 4, and 6 months of age and at 12 to 15 months of age. IPV is administered at 2, 4, and 6 months of age and at 4 to 6 years of age. PCV is administered at 2, 4, and 6 months of age and at 12 to 15 months of age. The first dose of MMR vaccine is administered at 12 to 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of HepB is administered at birth, the second dose is administered at 1 month of age, and the third dose is administered at 6 months of age. Varicella-zoster vaccine is administered at 12 to 15 months of age and again at 4 to 6 years of age. The nurse assesses a patient after a fall and determines the patient did not sustain any injury from the fall. After documenting in the patient's chart and completing the incident report what action should the nurse perform next? Update the nursing note to indicate the incident report was completed. Notify the nurse supervisor the patient had a fall. Notify housekeeping to clean the patient's room. Reassess the patient. #4 Rationale: The nurse must frequently reassess the patient because complications from injury may not always appear immediately after a fall. The nurse is providing discharge instructions to the family of an older adult client who is bedridden. The nurse should instruct the family that the most effective way to prevent urinary incontinence associated with immobility is to 1. apply a barrier moisture cream. 2. use absorbent under pads. 3. set up a toileting schedule. 4. restrict fluid intake. 3; set up a schedule Four clients recently returned to the unit following invasive diagnostic testing. The nurse should immediately intervene if one of the clients: (Scroll for Answer) A. Reports blood-tinged sputum following a bronchoscopy B. Has decreased abdominal girth following paracentesis C. Reports a headache following a lumbar puncture D. Is observed flexing and extending the legs two hours after femoral cardiac catheterization D. Following cardiac catheterization of the femoral artery, the client remains on bedrest for 2 to 6 hours with the affected leg straight and the head of the bed elevated to 30 degrees; blood tinged sputum is an expected finding after bronchoscopy; removal of fluid from the peritoneal cavity as in paracentesis will result in decreased abdominal girth; post lumbar puncture headache ranging from mild to severe may appear a few hours to days following the procedure. The registered nurse from the postpartum unit has been temporarily assigned to the medical-surgical unit. It would be most appropriate to assign this nurse to the client who A. has returned from right total hip replacement surgery four hours ago B. is being observed for increased intracranial pressure C. had surgery two hours ago to remove the appendix D. is two weeks post-partum being maintained on a mechanical ventilator for respiratory failure C The management of a client following abdominal surgery is standard. The postpartum nurse routinely cares for mothers following caesarean section; therefore it is appropriate to assign this client; The other choices are not appropriate to assign to this nurse. The nurse manager of a medical-surgical unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. (Scroll for Answer) 1. Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable 2. Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias 3. Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma 4. Client who is vomiting, unable to take oral fluids, and receiving intravenous fluids at 125 mL/hr 5. Client on nasal oxygen at 3 L/min, bibasilar crackles, and pulse oximetry readings of 88% to 92% 6. Client with white blood cell count of 2200 mm3(2.2 × 109/L), temperature of 102°F (38.9°C), and blood pressure of 90/40 mm Hg 1,2,3 Clients in options 1, 2, and 3 demonstrate no evidence of instability and can be discharged safely. The client in option 4 is demonstrating impaired gas exchange and fluid overload and requires oxygen. The client in option 5 requires intravenous fluid replacement because of vomiting. Without fluid replacement, the client is at risk for dehydration and electrolyte imbalances. The client in option 6 demonstrates signs of infection and hemodynamic instability and is at risk for developing septic shock. These clients should not be discharged at this time. The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? (Scroll for Answer) Sustained tissue damage Requires nasogastric suction Has a history of Addison's disease Uric acid level of 9.4 mg/dL (559 mmol/L) 2, The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia. A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? (Scroll for Answer) Hematuria and pyuria Hematuria and urgency Dysuria and proteinuria Dysuria and penile discharge 4, Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays. Hematuria is not associated with urethritis. Proteinuria is associated with kidney dysfunction. Hemoglobin- Hgb 12-18 Hematocrit- Hct 37-52 WBC 5-10 Platelet 150-400 Prothrombin time-PT 11-12.5 seconds INR 0.9-1.2 seconds PTT 20-30 seconds Aptt 30-40 seconds Sodium-Na 135-145 Potassium- K 3.5-5 Creatinine 0.5-1.2 Calcium-Ca 9-10.5 Chloride-Cl 98-106 Billirubin 0.3-1 Albumin 3.5-5 Iron (child) 50-120 Magnesium 1.5-2.5 Specific gravity 1.005-1.030 Newborn VS HR: 110-170 BP: 60-85/40-55 Temp: 97.6-99.3 RR: 30-60 Infant VS HR: 90-160 BP: 65-100/55-65 temp: 97.6-99.5 RR: 30-53 Toddler VS HR: 80-140 BP: 90-105/55-70 temp: 97.6-99.5 RR: 22-37 Preschooler VS HR: 75-120 BP: 95-110/60-75 RR: 20-28 School Age VS HR: 70-100 BP: 100-120/60-75 RR: 18-25 Adolescent VS HR: 60-100 BP: 110-125/65-85 RR: 12-20 A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? Hematuria and pyuria Hematuria and urgency Dysuria and proteinuria Dysuria and penile discharge 4, Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays. Hematuria is not associated with urethritis. Proteinuria is associated with kidney dysfunction. The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? (Scroll for Answer) A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic treatment A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of a gastrostomy feeding tube the next day A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for a computed tomography (CT) scan of the head 2, The infant or child who is the most unstable should be assessed first. A 6-week-old infant with an altered level of consciousness suspected to have resulted from shaken baby syndrome is the most unstable client because the infant could be developing increased intracranial pressure (ICP) and require interventions for the complications associated with increased ICP. The 6-year-old child on day 10 of antibiotics for bacterial meningitis is a stable client. The 2-year-old child with cerebral palsy being admitted for surgical placement of a gastrostomy tube will need an admission assessment, but this child is stable. The 16-year-old with a possible shunt malfunction could become unstable, but because this child is older and ready for the CT scan, he or she is stable at this time. The nurse is reviewing the client's arterial blood gas (ABG) results and notes the following values: pH: 7.35; PaO2: 80 mm Hg; PaCO2: 55mmHg; HCO: 30mEq/L. The nurse should recognize that this result is suggestive of which acid base imbalance? (Scroll for Answer) A.Compensated metabolic acidosis B.Compensated respiratory acidosis C.Compensated metabolic alkalosis D.Compensated metabolic alkalosis B - the pH is within normal range while the carbon dioxide level is increased indicating compensated respiratory acidosis When educating a patient about inject-able influenza immunization, the registered nurse considers the following... It is contraindicated during pregnancy. Its use is limited to children older than 6 years old. It contains a live virus. Its use is recommended for virtually all children age 6 months to 18 years old. 4 This vaccine can be given to infants 6 months and older. A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? A. "The medication will help dilate the eye to prevent pressure from occurring." B. "The medication will relax the muscles of the eyes and prevent blurred vision." C. "The medication causes the pupil to constrict and will lower the pressure in the eye." D. "The medication will help block the responses that are sent to the muscles in the eye." C Miotic medications cause constriction of the pupil. This will allow the extra fluid to drain from the eye and relieve the pressure. The nurse is caring for a client who has had spinal fusion, with the insertion of hardware. The nurse would be most concerned with which assessment finding? (Scroll for Answer) Temperature of 101.6°F (38.7°C) orally Complaints of discomfort during repositioning Old bloody drainage outlined on the surgical dressing Discomfort during coughing and deep-breathing exercises 1, The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6°F (38.7°C) should be reported. The nurse is planning care for a client who has amyotrophic lateral sclerosis (ALS). Which of the following interventions is most important for the nurse to include? 1. Increase periods of exercise 2. Establish alternative methods of communication 3. Coughing every two hours 4. Verbalization of feelings about the diagnosis 3- protect airway The nurse is assessing a client who has been admitted to the coronary care unit. The client seems to fluctuate in the ability to focus during the day. On the basis of this assessment, which client problem should the nurse suspect? Dementia as a result of isolation Dementia as a result of substance intoxication Acute confusion as a result of hospital-induced psychosis Interruption in the family as a result of alcohol withdrawal 3 Dementia patients have memory loss, mental decline, confusion in the evening hours, disorientation, irritability, personality changes, anxiety, loneliness, depression. In this situation, there is no indication of dementia, alcohol or drug use. After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? (Scroll for Answer) Reposition the laboring woman to knee-chest. Assess the vagina and cervix with a gloved hand. Notify the health care provider of the need for an amnioinfusion. Document the description of the fetal bradycardia in the nursing notes. 2. It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action should be to glove the examining hand and insert 2 fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.