Nokea
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.
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The nurse is caring for a client in labor who reports intense pressure and the urge to push. What is the priority nursing action?
- A. Perform a sterile vaginal examination.
- B. Instruct the client to breathe through the urge to push.
- C. Notify the healthcare provider.
- D. Increase the oxytocin infusion rate.
Correct Answer: A
Rationale: A vaginal examination is needed to confirm full cervical dilation and readiness for delivery.
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.
The nurse provides education regarding female sterilization. What important information is provided?
- A. “You will need to wait 3 months before you are sterile.â€
- B. “You can have this procedure in the hospital after you give birth.â€
- C. “Fertilization will affect your milk supply for breast-feeding.â€
- D. “Tubal ligation is reversible.â€
Correct Answer: D
Rationale: The important information provided regarding female sterilization is that tubal ligation, which is a form of female sterilization, is generally considered irreversible. This means that it is a permanent method of contraception and should not be relied upon as a temporary solution. It is important for individuals considering this procedure to understand that it is meant to be permanent and should be approached as such. If there is any consideration for future fertility, alternative contraceptive options should be discussed with a healthcare provider.
What is the primary reason for administering Rh immunoglobulin to an Rh-negative mother after delivery?
- A. To prevent maternal sensitization in future pregnancies
- B. To treat postpartum hemorrhage
- C. To reduce the risk of infection
- D. To boost maternal immune response
Correct Answer: A
Rationale: Rh immunoglobulin prevents maternal sensitization to Rh-positive blood.
The nurse is seeing a 17-year-old female in the clinic for complaints of acne. The nurse plans on taking advantage of this teachable moment with the teen. Which topics will the nurse include in the teen's teaching plan?
- A. Smoking habits, folic acid intake, and heart disease
- B. Hyperlipidemia, distracted driving, and menstrual history
- C. Sexual activity, contraception, and screening for violence
- D. Optimum weight, hypothyroidism, and sexually transmitted diseases
Correct Answer: D
Rationale: The most appropriate topics for the nurse to include in the teaching plan for the 17-year-old female with acne are optimum weight, hypothyroidism, and sexually transmitted diseases. Acne can be influenced by hormonal changes, which can be impacted by weight, thyroid function, and hormonal fluctuations related to sexual health. Educating the teen about these topics can help her understand potential contributing factors to her acne and empower her to make informed decisions about her health and lifestyle. It is important to address issues that are relevant to the teen's current health concerns while also providing valuable information for her overall well-being.