A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor?

Slow change in dilation and effacement

Contraction intensity increased by ambulation

Presence of bloody show

Intermittent, painless contractions

Answer and Explanation

The Correct Answer is D

Rationale:

A. Slow change in dilation and effacement: Even slow cervical changes are indicative of true labor. False labor does not cause any progressive cervical dilation or effacement, making this an inconsistent finding for false labor.

B. Contraction intensity increased by ambulation: In true labor, contractions typically intensify with activity such as walking. In contrast, false labor contractions often diminish or resolve with changes in position or ambulation.

C. Presence of bloody show: Bloody show results from cervical dilation and the disruption of cervical capillaries. It is a hallmark of true labor and would not be expected during false labor.

D. Intermittent, painless contractions: False labor is characterized by irregular, non-progressive, and typically painless contractions, often referred to as Braxton Hicks contractions. These are normal in late pregnancy but do not indicate true labor.

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Correct Answer is C

Explanation

Rationale:

A. Tomato allergy: A tomato allergy is not relevant to the ingredients used in total parenteral nutrition (TPN) with fat emulsion. Tomatoes are not a component of lipid emulsions, so this does not present a concern in this context.

B. Citrus allergy: Citrus fruits are also not involved in the formulation of fat emulsions or TPN components. Therefore, a citrus allergy would not require special precautions related to the prescribed therapy.

C. Egg allergy: Lipid emulsions used in TPN often contain egg phospholipids as an emulsifying agent. Clients with an egg allergy may experience a hypersensitivity reaction, making this a critical finding that must be reported to the provider immediately.

D. Wheat allergy: Wheat is not a component of standard TPN or fat emulsions. While wheat allergies are significant for dietary intake, they do not pose a known risk with parenteral nutrition administration.

A. Place the oxygen tank away from curtains or drapes. B. Store the oxygen tank wrench in a locked cabinet. C. Ensure that the client checks the gauge weekly. D. Have the client store smaller tanks under his bed.

Correct Answer is A

Explanation

Rationale:

A. Place the oxygen tank away from curtains or drapes: Oxygen supports combustion, so tanks must be kept away from flammable materials such as curtains or drapes. This placement reduces fire risk and ensures safe home oxygen use.

B. Store the oxygen tank wrench in a locked cabinet: The tank wrench should remain attached to or easily accessible near the tank for emergency shut-off. Locking it away could delay quick responses during equipment malfunction or fire hazards.

C. Ensure that the client checks the gauge weekly: Oxygen tank levels should be checked daily to prevent running out unexpectedly. Waiting a week between checks increases the risk of the tank depleting before a refill is arranged.

D. Have the client store smaller tanks under his bed: Storing tanks under the bed poses a fire hazard due to limited ventilation and proximity to bedding. Oxygen tanks should be stored upright in a secure, well-ventilated area away from heat sources.

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A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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