Nokea
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
- A. When did your contractions begin?
- B. Have you noticed any bloody show or fluid coming from your vagina?
- C. What happens to your contractions when you move about?
- D. Have you felt fetal movement over the last 24 hours?
Correct Answer: B
Rationale: The correct answer is B: "Have you noticed any bloody show or fluid coming from your vagina?" This question helps differentiate true labor from false labor because the presence of bloody show or amniotic fluid suggests cervical changes associated with true labor. Bloody show indicates the shedding of the cervical mucus plug, and amniotic fluid leakage indicates rupture of membranes. This information helps confirm the progression of labor.
Choice A: "When did your contractions begin?" is a general question that does not specifically differentiate between true and false labor.
Choice C: "What happens to your contractions when you move about?" is more related to the management of labor rather than differentiating true labor from false labor.
Choice D: "Have you felt fetal movement over the last 24 hours?" is important for assessing fetal well-being but does not help in distinguishing true labor from false labor.
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A nurse is preparing to take a rectal temperature on a 7-month-old infant. Which of the following should the nurse keep in mind when preparing to take the temperature?
- A. A well-lubricated thermometer tip should be inserted a maximum of 2.5 in into the rectum.
- B. A rectal temperature of 99.6° F is equal to an oral temperature of 97.7° F.
- C. Infants should have temperatures taken rectally for accuracy and thermoregulation.
- D. Mercury thermometers are the thermometers of choice to obtain the rectal temperature, holding it in place for 4 min.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The correct answer is B because rectal temperatures are typically 1.5-2°F higher than oral temperatures due to the body's core temperature being higher internally. This conversion is essential in accurately interpreting the infant's rectal temperature.
Summary of other choices:
A: Incorrect. The maximum insertion depth for a rectal thermometer in infants is 1 inch, not 2.5 inches.
C: Incorrect. Rectal temperatures are not the only accurate method for infants; axillary or temporal artery thermometers are also reliable.
D: Incorrect. Mercury thermometers are no longer recommended due to the risk of mercury exposure, and the time required to obtain a rectal temperature is typically shorter.
The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate?
- A. Instruct the mother to breathe slowly because this is a sign of hyperventilation
- B. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions
- C. Turn the woman onto her left side to relieve pressure on the umbilical cord
- D. Reduce the oral and IV fluids to decrease circulatory overload
Correct Answer: C
Rationale: The correct answer is C: Turn the woman onto her left side to relieve pressure on the umbilical cord. Variable decelerations are associated with umbilical cord compression. Turning the woman onto her left side can help relieve pressure on the cord, improving fetal oxygenation. This position change is a non-invasive, quick intervention that can potentially resolve the variable decelerations.
Choice A is incorrect because variable decelerations are not typically associated with hyperventilation. Choice B is incorrect as decreasing Pitocin may not directly address the underlying cause of the variable decelerations. Choice D is incorrect because reducing fluids may not address the immediate concern of umbilical cord compression.
A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
- A. Administer antiviral medication
- B. Schedule an ultrasound examination
- C. Administer Haemophilus influenza type b vaccine
- D. Schedule an indirect Coombs’ test
Correct Answer: B
Rationale: The correct answer is B: Schedule an ultrasound examination. Parvovirus B19 in pregnancy can lead to complications such as fetal hydrops. An ultrasound can monitor fetal well-being and detect any abnormalities. Administering antiviral medication (A) is not typically recommended for parvovirus B19. Administering the Haemophilus influenza type b vaccine (C) is unrelated to this condition. Performing an indirect Coombs' test (D) is used to detect maternal antibodies in Rh incompatibility, not related to parvovirus B19.
A nurse is caring for a 7-year-old child who is admitted with an asthma exacerbation.
- A. "Monitoring oxygen saturation and respiratory rate daily."'
- B. "Identification and avoidance of factors that trigger symptoms."'
- C. "Monitoring peak flow measurements regularly."'
- D. "Positioning the client upright in a position of comfort."'
Correct Answer: B
Rationale: The correct answer is B because identifying and avoiding triggers helps prevent asthma exacerbations. This proactive approach addresses the root cause of the issue, promoting long-term management. Monitoring oxygen saturation, respiratory rate, and peak flow are important but reactive measures, not addressing the underlying triggers. Positioning upright aids breathing but does not prevent exacerbations.
Which data support a diagnosis of abruptio placenta in a pregnant woman?
- A. Uterine rigidity and abdominal pain
- B. Painless bleeding with soft abdomen
- C. Premature rupture of membranes and uterine contractions
- D. Bright red blood loss and elevated blood pressure
Correct Answer: A
Rationale: The correct answer is A: Uterine rigidity and abdominal pain. Abruptio placenta is characterized by premature separation of the placenta from the uterine wall. Uterine rigidity indicates the presence of a hypertonic uterus due to the sudden hemorrhage, leading to severe abdominal pain. This is a classic presentation of abruptio placenta. Choices B, C, and D do not align with the typical clinical features of abruptio placenta. Painless bleeding with a soft abdomen does not suggest an acute and painful condition like abruptio placenta. Premature rupture of membranes and uterine contractions are more indicative of preterm labor or premature rupture of membranes, not abruptio placenta. Bright red blood loss and elevated blood pressure are more characteristic of placenta previa or preeclampsia, respectively, not abruptio placenta.