Nokea
Which assessment finding indicates that placental separation has occurred during the third stage of labor?
- A. Decreased vaginal bleeding
- B. Contractions stop
- C. Maternal shaking and chills
- D. Lengthening of the umbilical cord
Correct Answer: D
Rationale: The correct answer is D: Lengthening of the umbilical cord. This indicates placental separation as the placenta detaches from the uterine wall, causing the cord to lengthen. A: Decreased vaginal bleeding is incorrect as bleeding typically increases due to separation. B: Contractions stopping is not indicative of placental separation but can occur after the placenta is delivered. C: Maternal shaking and chills are signs of postpartum shivering, not placental separation.
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A woman in active labor is admitted to the labor and delivery unit, accompanied by her partner. As labor progresses, the nurse notes he is not interacting with the woman and sits in the corner, looking out the window. How may the nurse understand the man's actions?
- A. He is likely to be very concerned about the woman's health to the point that his ability to cope with the situation is compromised
- B. His actions reflect personality or cultural differences, which do not necessarily indicate a lack of concern.
- C. Due to his embarrassment and discomfort regarding the woman's expressions of pain, he withdraws from the situation
- D. His religious beliefs regarding participation in the birth experience affect his interactivity and communication in this situation.
Correct Answer: B
Rationale: The correct answer is B because it recognizes that the man's actions may be influenced by his personality or cultural differences, rather than indicating a lack of concern. This choice acknowledges that individuals may react differently in stressful situations based on their upbringing, beliefs, or personal characteristics. This understanding is crucial for the nurse to provide appropriate support and address any potential misunderstandings.
Choice A suggests that the man's concern about the woman's health is compromising his ability to cope, which is not supported by the information provided. Choice C assumes the man's withdrawal is due to embarrassment and discomfort, which may not be the case. Choice D attributes the man's behavior to religious beliefs, which is not mentioned in the scenario. These choices do not align with the evidence presented and do not consider the complexity of human behavior in different contexts.
A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
A client asks the nurse about the benefits of breastfeeding. Which response by the nurse provides the most accurate information?
- A. Breastfeeding helps women lose weight faster.
- B. Breast milk contains a greater amount of protein.
- C. Breast milk is easier to digest than formula.
- D. Breastfeeding is a good method of contraception.
Correct Answer: C
Rationale: The correct answer is C: Breast milk is easier to digest than formula. Breast milk contains specific enzymes and antibodies that aid in digestion and are easily absorbed by the baby's immature digestive system. This promotes better nutrient absorption and reduces the risk of digestive issues. Option A is incorrect because weight loss varies for each woman and should not be the primary reason for breastfeeding. Option B is incorrect as breast milk has a balanced composition of nutrients, not just higher protein content. Option D is incorrect as breastfeeding is not a reliable form of contraception.
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
- A. When did your contractions begin?
- B. Have you noticed any bloody show or fluid coming from your vagina?
- C. What happens to your contractions when you move about?
- D. Have you felt fetal movement over the last 24 hours?
Correct Answer: B
Rationale: The correct answer is B: "Have you noticed any bloody show or fluid coming from your vagina?" This question helps differentiate true labor from false labor because the presence of bloody show or amniotic fluid suggests cervical changes associated with true labor. Bloody show indicates the shedding of the cervical mucus plug, and amniotic fluid leakage indicates rupture of membranes. This information helps confirm the progression of labor.
Choice A: "When did your contractions begin?" is a general question that does not specifically differentiate between true and false labor.
Choice C: "What happens to your contractions when you move about?" is more related to the management of labor rather than differentiating true labor from false labor.
Choice D: "Have you felt fetal movement over the last 24 hours?" is important for assessing fetal well-being but does not help in distinguishing true labor from false labor.
A nurse is preparing to administer an intramuscular (IM) injection to a 2-month-old infant. Which of the following is the preferred injection site?
- A. "Vastus lateralis"'
- B. "Deltoid muscle"'
- C. "Ventrogluteal site"'
- D. NA
Correct Answer: A
Rationale: The correct answer is A: "Vastus lateralis." For infants, the vastus lateralis muscle in the thigh is the preferred site for IM injections due to its large size, well-developed muscle mass, and minimal major blood vessels and nerves. This reduces the risk of injury and ensures proper medication absorption. The deltoid muscle (choice B) is typically used for older children and adults, not infants. The ventrogluteal site (choice C) is more commonly used for adults and older children as well. Not Applicable (choice D) does not provide any relevant information.