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Primigravida client at term, having contractions, unsure if in labor
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is 'not really sure if she is in labor or not.' Which of the following should the nurse recognize as a sign of true labor?
- A. Rupture of the membranes.
- B. Pattern of contractions.
- C. Changes in the cervix.
- D. Station of the presenting part.
Correct Answer: C
Rationale: Changes in the cervix, such as effacement and dilation, are the most accurate indicators of true labor, caused by contractions and fetal pressure.
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Newborn boy, 1 minute after birth, heart rate 138 bpm, vigorous crying, spontaneous movement, pink skin with bluish hands and feet
Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. What Apgar score will be assigned to the baby?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: B
Rationale: The baby scores 2 for heart rate (>100 bpm), 2 for respiratory effort (vigorous crying), 2 for muscle tone (spontaneous movement), 2 for reflex irritability (crying), and 1 for color (acrocyanosis), totaling an Apgar score of 8.
Client in latent phase of labor for 12 hours, requesting medication to rest
A client in latent phase of labor for the past 12 hours is requesting medication to help her rest.
- A. Fentanyl
- B. Meperidine.
- C. Morphine.
- D. Secobarbital.
- E. Secobarbital.
Correct Answer: A
Rationale: Fentanyl is a fast-acting opioid suitable for pain relief and sedation in labor, with less risk of prolonged effects compared to other options.
Primigravida client in second stage of labor, moaning and screaming, husband requests pain medication
A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
- A. Assist the client with breathing and imagery techniques in an attempt to calm her down.
- B. Ask the client to describe the intensity of her pain on a scale of 0 to 10.
- C. Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication.
- D. Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk.
Correct Answer: A
Rationale: Assisting with breathing and imagery techniques provides nonpharmacological pain relief and supports the client's coping mechanisms, which is appropriate as vocalizing is a normal way to express pain during labor.
Student nurse learning about milk production
The student nurse learns that the hormone necessary for milk production is
- A. Estrogen.
- B. Prolactin.
- C. Progesterone.
- D. Lactogen.
Correct Answer: B
Rationale: Prolactin, secreted by the pituitary gland, is responsible for milk production, especially after delivery when estrogen and progesterone levels drop.
1-day-old newborn, indented anterior fontanelle
The nurse notices while holding him upright that a 1-day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate?
- A. Increased intracranial pressure.
- B. Vernix caseosa.
- C. Dehydration.
- D. Cyanosis.
Correct Answer: C
Rationale: An indented anterior fontanelle most likely indicates dehydration, as fluid loss causes the fontanelle to sink.