Nokea
A client who is 37 weeks gestation comes to the office for a routine visit. This is the client's first baby and she asks the nurse how she will know when labor begins. Which signs indicate that true labor has begun?
- A. Contractions that are irregular and decrease in intensity when walking
- B. Abdominal pain that starts at the fundus and progresses to the lower back
- C. Increased pressure on the bladder and urinary frequency
- D. Expulsion of pink-tinged mucous and contractions that start in the lower back
Correct Answer: D
Rationale: The correct answer is D because the expulsion of pink-tinged mucous (bloody show) and contractions starting in the lower back are indicative of true labor. This is due to the release of the mucus plug and the initiation of true uterine contractions. Contractions that start in the lower back and progress to the front are characteristic of true labor.
Choice A is incorrect because contractions that are irregular and decrease in intensity with walking are characteristic of false labor (Braxton Hicks contractions).
Choice B is incorrect as abdominal pain starting at the fundus and progressing to the lower back is not a specific sign of true labor.
Choice C is incorrect as increased pressure on the bladder and urinary frequency are common throughout pregnancy and not specific to the onset of true labor.
In summary, the correct answer D provides specific and characteristic signs of true labor, while the other choices do not accurately reflect the onset of true labor.
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The nurse performs Leopold's maneuvers for a client admitted in labor. Which is the main goal of Leopold's maneuvers?
- A. To determine whether the client's cervix has dilated
- B. To assess the frequency and intensity of the contractions
- C. To assess whether membranes have been ruptured
- D. To determine the presentation and position of the fetus
Correct Answer: D
Rationale: The correct answer is D: To determine the presentation and position of the fetus. Leopold's maneuvers involve a series of palpations to assess the fetal lie, presentation, position, and engagement. By performing these maneuvers, the nurse can determine the position of the fetus in relation to the mother's pelvis and whether the baby is in a vertex or breech presentation. This information is crucial in planning for a safe delivery and identifying any potential complications.
Other choices are incorrect because:
A: Leopold's maneuvers do not directly assess cervical dilation.
B: Contractions are typically monitored separately using a tocodynamometer.
C: Checking for ruptured membranes is done through a separate assessment.
In summary, Leopold's maneuvers primarily focus on assessing the presentation and position of the fetus to guide the delivery process effectively.
A nurse is initiating a plan of care for a toddler who is hospitalized. Which of the following instructions is important to communicate to the nursing assistant?
- A. Have the toddler dress himself.
- B. Offer the toddler finger foods for snacks.
- C. Provide opportunities to share toys with others.
- D. Ask the child simple yes or no questions.
Correct Answer: B
Rationale: The correct answer is B: Offer the toddler finger foods for snacks. This instruction is important to communicate to the nursing assistant because toddlers are at risk for choking on certain foods due to their developing chewing and swallowing abilities. Finger foods are safer for toddlers to eat as they are easier to manage and reduce the risk of choking.
Other choices are incorrect because:
A: Having the toddler dress himself may not be appropriate as toddlers may need assistance and supervision due to their limited motor skills.
C: Providing opportunities to share toys with others is important for social development but is not as critical as ensuring the toddler's safety during meal times.
D: Asking the child simple yes or no questions is a good communication strategy but not as essential for the toddler's safety during snack times.
A labor and delivery nurse suspects that a client is in the transition stage of labor. Which information supports this conclusion? The client is:
- A. walking around the unit and talking with her partner.
- B. irritable and needs frequent repetition of directions.
- C. expelling feces and the fetal head is crowning.
- D. reading a magazine and talking on the phone.
Correct Answer: B
Rationale: The correct answer is B. In the transition stage of labor, the cervix dilates from 8 to 10 cm. This stage is characterized by intense contractions, increased irritability, and the need for frequent repetition of directions due to the intensity of labor pain. The client being irritable and needing frequent repetition of directions indicates that she is likely in the transition stage of labor.
A: Walking around and talking with her partner is more indicative of the early stage of labor.
C: Expelling feces and the fetal head crowning are more indicative of the second stage of labor.
D: Reading a magazine and talking on the phone are not typical behaviors during the transition stage of labor.
A nurse is preparing a room for the admission of a client with sickle cell anemia who is in vasoocclusive crisis. Which type of equipment should the nurse place in the client's room?
- A. Wheelchair with adjustable leg rests
- B. A radio and age-appropriate reading materials
- C. Extra blankets and pillows
- D. Blood transfusion equipment
Correct Answer: D
Rationale: The correct answer is D: Blood transfusion equipment. In a vasoocclusive crisis, the client with sickle cell anemia may require blood transfusions to improve oxygen delivery to tissues. Having blood transfusion equipment readily available in the client's room ensures prompt initiation of treatment. Wheelchair (A) and comfort items like extra blankets and pillows (C) are important but not essential during a vasoocclusive crisis. A radio and reading materials (B) are not directly related to the client's immediate medical needs.
Which method of temperature regulation would safely and effectively prevent cold stress in a newly delivered infant?
- A. Wrap the baby loosely with a blanket.
- B. Be sure the baby's feet are covered.
- C. Cover the baby's head with a hat.
- D. Position the baby on a heating pad.
Correct Answer: C
Rationale: The correct answer is C: Cover the baby's head with a hat. Infants lose a significant amount of heat through their heads, so covering the head with a hat helps prevent heat loss and cold stress. Option A does not provide enough insulation to prevent cold stress. Option B only addresses the feet, while the head is a major heat loss area. Option D poses a risk of overheating and burns.