A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

A surge of energy

Urinary retention

Decreased vaginal discharge

Weight gain of 0.5 to 1.5 kg

Answer and Explanation

The Correct Answer is A

A.   A surge of energy: Some women experience a sudden burst of energy, often referred to as a "nesting" instinct, shortly before the onset of labor.
B.   Urinary retention: Urinary frequency and urgency are more common before labor, not urinary retention.
C.   Decreased vaginal discharge: Before labor, there might be an increase in vaginal discharge, often thick and pinkish, known as the "bloody show."
D.   Weight gain of 0.5 to 1.5 kg: Weight gain is not typically associated with the onset of labor.

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Correct Answer is C

Explanation

A. 1 cm below the umbilicus: This is too low for a client at 22 weeks of gestation.

B. 3 cm below the umbilicus: This is also too low for a client at 22 weeks of gestation.

C. 2 cm above the umbilicus: At 22 weeks of gestation, the fundus should be palpated about 2 cm above the umbilicus, which is at approximately the level of the maternal belly button.
D. 3 cm above the umbilicus: This is too high for a client at 22 weeks of gestation.

A. The client requires a rubella vaccination at this time. B. The client is not experiencing a rubella infection at this time. C. The client requires a rubella immunization following delivery. D. The client is immune to the rubella virus.

Correct Answer is C

Explanation

A. The client requires a rubella vaccination at this time. This is incorrect because rubella vaccination is contraindicated during pregnancy due to the risk of congenital rubella syndrome. Vaccination should be administered postpartum.

B. The client is not experiencing a rubella infection at this time. While this statement is true, it does not address the need for future immunization, which is the critical aspect of the interpretation.

C. The client requires a rubella immunization following delivery. This is correct because a negative rubella titer indicates that the client is not immune to rubella and should receive the vaccine postpartum to prevent future infection.

D. The client is immune to the rubella virus. This is incorrect because a negative rubella titer indicates a lack of immunity to rubella, meaning the client is susceptible to infection.

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A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is C

Explanation

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

Correct Answer is C

Explanation

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

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