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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While the hepatitis B vaccine is an important part of preventing hepatitis B infection, it is not typically given on a monthly basis until the newborn tests negative for the hepatitis B surface antigen. Instead, the vaccine is usually given in a series of three to four doses over a six-month period.
Choice B rationale
For newborns who test positive for the hepatitis B surface antigen, the current recommendation is to administer both the hepatitis B immune globulin (HBIG) and the
hepatitis B vaccine within 12 hours of birth. The HBIG provides immediate, short-term protection against the virus, while the vaccine stimulates the newborn’s immune system to provide long-term protection.
Choice C rationale
While the hepatitis B immune globulin (HBIG) and the hepatitis B vaccine are both important for preventing hepatitis B infection in newborns, they are not typically administered in the manner described in this choice. The HBIG is usually given once, within 12 hours of birth, while the vaccine is given in a series of three to four doses over a six-month period.
Choice D rationale
The hepatitis B vaccine is typically given within 24 hours of birth, but it is not followed by doses of the hepatitis B immune globulin (HBIG) every 12 hours for three days. Instead, a single dose of HBIG is usually given within 12 hours of birth, along with the first dose of the vaccine.
Correct Answer is D
Explanation
Choice A rationale
While changes in an infant’s sleep patterns can be a sign of many issues, they are not a specific indicator of a food allergy.
Choice B rationale
Rice cereals are typically one of the first foods introduced to infants and are usually well- tolerated. They are not known to cause problems during lactation.
Choice C rationale
The foods a mother eats can affect breast milk, but they do not typically cause food allergies. Most babies can tolerate a variety of foods in a mother’s diet without any problems.
Choice D rationale
If there is a strong family history of peanut allergies, the mother might want to avoid eating peanuts while breastfeeding. However, current research suggests that early exposure to potential allergens may actually decrease the risk of developing allergies.
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