A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor.
The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.
Constipation.
Weight gain.
Bloody show.
Lightening.
Backache.
Correct Answer : C
The correct answers are choices C, D, and E.
Choice A rationale:
Constipation is not a sign of labor. It is more commonly associated with pregnancy rather than the onset of labor.
Choice B rationale:
Weight gain is not a sign of labor. In fact, weight gain often stops as labor approaches.
Choice C rationale:
Bloody show is a sign of labor. It is the discharge of the mucus plug that seals the cervix during pregnancy.
Choice D rationale:
Lightening, or the baby dropping into the pelvis, is a sign of labor.
Choice E rationale:
Backache can be a sign of labor, as the muscles and joints stretch and shift in preparation for childbirth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Heart rate and respiratory effort are two of the five parameters of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
Choice B rationale:
Temperature is not a parameter of the Apgar score. Tone is a parameter, but this choice is incomplete as it does not include all five parameters.
Choice C rationale:
Color is a parameter of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
Choice D rationale:
The Apgar score is based on five parameters: heart rate, breaths per minute (respiratory effort), irritability (response to stimulation), tone (muscle tone), and color. Therefore, this choice is correct.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.
Choice B rationale:
Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.
Choice C rationale:
The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.
Choice D rationale:
Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.
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