A nurse is attending to a client who is a first-time mother, at term, and experiencing contractions. She is uncertain if she is in labor.Which of the following would the nurse identify as an indication of true labor?

Pattern of contractions.

Rupture of the membranes.

Position of the presenting part.

Changes in the cervix.

Answer and Explanation

The Correct Answer is A

Choice A rationale
This is the correct answer. Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor.
Choice B rationale
Rupture of the membranes can occur before or during labor, but it is not a definitive sign of true labor.
Choice C rationale
The position of the presenting part is not a definitive sign of true labor.
Choice D rationale
Changes in the cervix can be a sign of true labor, but without regular, strong contractions, it is not a definitive sign.

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Correct Answer is ["A","C"]

Explanation

The correct answers are A. Transverse palmar creases and C. Protruding tongue.

Choice A rationale:

Transverse palmar creases, also known as a single palmar crease, are a common characteristic of Down syndrome. This feature is present in many individuals with the condition.

Choice B rationale:

Muscular hypertonicity (increased muscle tone) is not typical in Down syndrome. Instead, individuals with Down syndrome often have hypotonia (decreased muscle tone).

Choice C rationale:

A protruding tongue is a common characteristic of Down syndrome. This is due to a combination of factors, including a small oral cavity and low muscle tone.

Choice D rationale:

Large ears are not a typical feature of Down syndrome. Individuals with Down syndrome often have small or unusually shaped ears.

Choice E rationale:

Low birth weight is not specifically associated with Down syndrome. While some infants with Down syndrome may have low birth weight, it is not a defining characteristic.

A. Fundus at the level of the umbilicus B. Deep tendon reflexes 4+ C. Saturated perineal pad in 30 minutes D. Approximated edges of the episiotomy

Correct Answer is C

Explanation

Choice A rationale
A fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum.
Choice B rationale
Deep tendon reflexes of 4+ could indicate hyperreflexia, a sign of preeclampsia, but this is not the priority if the client has a saturated perineal pad in 30 minutes.
Choice C rationale
A saturated perineal pad in 30 minutes indicates heavy bleeding, which could be a sign of postpartum hemorrhage. This is a life-threatening condition and is therefore the priority.
Choice D rationale
Approximated edges of the episiotomy is a normal finding in a woman who is 4 hours postpartum.

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A nurse is attending to a client who is a first-time mother, at term, and experiencing contractions. She is uncertain if she is in labor.Which of the following would the nurse identify as an indication of true labor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who has Trisomy 21 (Down’s Syndrome). Which of the following are common characteristics? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

Correct Answer is C

Explanation

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