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The nurse is monitoring a client during the second stage of labor. What finding indicates that birth is imminent?
- A. Client reports the urge to push.
- B. Contractions are irregular.
- C. Fetal heart rate is 140 beats/minute.
- D. Cervix is dilated to 8 cm.
Correct Answer: A
Rationale: The urge to push is a sign that the baby is descending, indicating that delivery is near.
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The nurse is explaining how a newly delivered baby initiates respiration. Which statement explains this process?
- A. Chemical thermal and mechanical factors
- B. Increase of po2 and decreased pco2
- C. Continued function of foramen ovale
- D. Drying off the infant
Correct Answer: A
Rationale: The correct statement explaining how a newly delivered baby initiates respiration is "Chemical thermal and mechanical factors." When a baby is born, various factors come into play to stimulate the baby's first breath. Chemically, the baby senses a decrease in oxygen and an increase in carbon dioxide levels, triggering the respiratory centers in the brain to start the breathing process. Thermally, exposure to the cooler air outside the womb stimulates the baby's skin receptors, encouraging the baby to take a breath. Mechanically, the pressure changes during delivery and the physical stimulation of the baby's face and body also play a role in initiating respiration. Overall, it is the combined effect of these chemical, thermal, and mechanical factors that help a newly delivered baby begin breathing independently.
A nurse is providing teaching to a client about exercise safety during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply).
- A. "will limit my time in the hot tub to 30 minutes after exercise."
- B. "should consume three 8-ounce glasses of water after I exercise."
- C. "will check my heart rate every 15 minutes during exercise sessions."
- D. "should limit exercise sessions to 30 minutes when the weather is humid."
Correct Answer: C
Rationale: This response indicates an understanding of the importance of monitoring heart rate during exercise to ensure it stays within a safe range for the pregnant woman and the baby.
A patient is about to undergo an amniocentesis. tion on her postpartum clients. Which client has a Which procedures should the nurse perform? Select high risk for postpartum hemorrhage? Select all all that apply.
- A. Have the patient give verbal consent for the
- B. Client who delivered vaginally at 40 weeks procedure.
- C. Client who delivered by cesarean delivery because
- D. Assess for bleeding disorders.
Correct Answer: A
Rationale: Having the patient give verbal consent for the procedure is a standard practice and an important step to ensure that the patient understands the risks and benefits of the amniocentesis.
The nurse is teaching a client about signs of labor. Which symptom indicates true labor?
- A. Irregular contractions that stop with activity.
- B. Contractions felt in the abdomen only.
- C. Cervical dilation and effacement.
- D. Absence of fetal movement.
Correct Answer: C
Rationale: True labor is characterized by regular contractions that cause cervical dilation and effacement.
The nurse is caring for a postpartum client with a perineal laceration. What comfort measure is most appropriate?
- A. Encourage warm sitz baths.
- B. Apply warm compresses to the perineum.
- C. Provide a heating pad for the lower abdomen.
- D. Offer an ice pack for the perineum.
Correct Answer: D
Rationale: Ice packs help reduce swelling and discomfort in the perineal area during the initial postpartum period.