Nokea
The pregnant client presents with Drag and Drop contractions that she describes as strong in intensity. Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information?
- A. The client is experiencing early labor.
- B. The client is experiencing false labor.
- C. The client has experienced cervical ripening.
- D. The client has experienced lightening.
Correct Answer: A
Rationale: Early labor is a pattern of labor that occurs when contractions become Drag and Drop and the cervix dilates to 3 cm. False labor occurs when Braxton-Hicks contractions are strong enough for the client to believe she is in actual labor. The contractions are infrequent or do not have a definite pattern. The lack of cervical change is also consistent with false labor. The latent phase is characterized by Drag and Drop contractions, although fetal descent may not occur. Cervical ripening (softening, effacement, and increased distensibility) begins about 4 weeks before birth. There is no information in the stem about cervical ripening. Lightening is settling or lowering of the fetus into the pelvis. Lightening can occur a few weeks or a few hours before labor. There is no information in the stem about lightening.
You may also like to solve these questions
The primiparous client, who is bottle feeding her infant, asks the nurse when she can expect to start having her menstrual cycle again. Which response by the nurse is most accurate?
- A. “Most women who bottle feed can expect their period within 6 to 10 weeks after birth.”
- B. “Your period should return a few days after your lochial discharge stops.”
- C. “Your lochia will change from pink to white; when white, your period should return.”
- D. “Bottle feeding delays the return of a normal menstrual cycle until 6 months postbirth.”
Correct Answer: A
Rationale: In nonlactating women, the average time to first ovulation is 45 days, and the return of menstruation usually happens within 6 to 10 weeks postbirth. Most women can expect to have lochial discharge for up to 24 days. However, the cessation of discharge is not related to the return of menstruation. The change in lochial color is not related to the return of menstruation. The return of ovulation and menstruation is associated with a rise in serum progesterone levels. Bottle feeding does not affect when this change occurs in the client’s body.
In the process of preparing the client for discharge after cesarean section, the nurse addresses all of the following areas during discharge education. Which should be the priority advice for the client?
- A. How to manage her incision
- B. Planning for assistance at home
- C. Infant care procedures
- D. Increased need for rest
Correct Answer: B
Rationale: Although the client needs information about incision care, the priority need is for assistance at home so that she can get the rest needed for multiple demands. Because the client has had a surgical procedure, the priority consideration is for the mother to plan for additional assistance at home. Without this assistance, it is difficult for the mother to get the rest she needs for healing, pain control, and appropriate infant care. Infant care is important, but having assistance at home after a surgical procedure is more important. The need for increased rest is important, but she would not be able to obtain adequate rest without assistance at home.
The nurse is caring for the pregnant client at 20 weeks’ gestation. At what level should the nurse expect to palpate the client’s uterine height?
- A. Two finger-breadths above the symphysis pubis
- B. Halfway between the symphysis pubis and the umbilicus
- C. At the level of the umbilicus
- D. Two finger-breadths above the umbilicus
Correct Answer: C
Rationale: At 20 gestational weeks, the uterus should be at the level of the umbilicus. The uterine height is too low for 20 weeks’ gestation. At 13 weeks, the uterus would be approximately two finger-breadths above the symphysis pubis. The uterine height is too low for 20 weeks’ gestation. At 16 weeks, the uterus would be approximately halfway between the umbilicus and symphysis pubis. The uterine height is too high for 20 weeks’ gestation. At 22 weeks, the uterus would be two finger-breadths above the umbilicus.
The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?
- A. Conclude that there is a problem with the baby and call for help.
- B. Check that there is adequate gel under the transducer and reposition.
- C. Give the client oxygen via facemask at 8 to 10 liters per minute.
- D. Auscultate fetal heart rate by fetoscope and assess maternal vital signs.
Correct Answer: B
Rationale: When the FHR monitor tracing is no longer recording, the nurse should first check for adequate gel under the transducer. There needs to be adequate gel under the transducer for good conduction, and adding gel frequently corrects the problem. Assessing for adequate gel under the transducer and repositioning should be done before assuming there is a problem with the baby’s HR. There is no indication to give oxygen to the client. Auscultating FHR by fetoscope and assessing maternal VS could be completed, but not until the transducer has been checked.
The first-trimester pregnant client asks the nurse if the activities in which she participates are safe in the first trimester. Which activity should the nurse verify as a safe activity during the client’s first trimester?
- A. Hair coloring
- B. Hot tub use
- C. Pesticide use
- D. Sexual activity
Correct Answer: D
Rationale: Sexual activity is not contraindicated in pregnancy unless a specific risk factor is identified. Hair coloring should be avoided in the first trimester because the chemicals can be absorbed and pose a risk to the developing fetus. Hot tub use should be avoided because it increases the client’s body temperature. Maternal hyperthermia during the first trimester raises concerns about possible spontaneous abortion, CNS defects, and failure of neural tube closure. Exposure to pesticides during pregnancy increases the risk for preterm birth, intrauterine growth restriction, childhood developmental delays, and infertility later in adulthood.