A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?
"You will experience urinary retention."
"You will have a decrease in vaginal discharge."
"You will experience a surge of energy."
"You will have a weight gain of 0.5 to 1.5 kilograms."
The Correct Answer is C
Choice A reason: "You will experience urinary retention." is incorrect, as this statement does not describe a sign preceding the onset of labor. Urinary retention can occur during labor due to pressure from the fetal head or epidural anesthesia, but it is not a sign that labor is imminent. The nurse should encourage the client to void frequently and monitor their bladder status.
Choice B reason: "You will have a decrease in vaginal discharge." is incorrect, as this statement does not describe a sign preceding the onset of labor. Vaginal discharge can increase before labor due to cervical ripening and dilation, which can cause bloody show or mucus plug loss. The nurse should educate the client about normal and abnormal vaginal discharge and when to report it.
Choice C reason: "You will experience a surge of energy." is correct, as this statement describes a sign preceding the onset of labor. A surge of energy, also known as nesting instinct, can occur before labor due to hormonal changes or psychological factors. The nurse should advise the client to conserve their energy and rest as much as possible before labor.
Choice D reason: "You will have a weight gain of 0.5 to 1.5 kilograms." is incorrect, as this statement does not describe a sign preceding the onset of labor. Weight gain can occur during pregnancy due to fetal growth, fluid retention, or increased caloric intake, but it is not a sign that labor is imminent. The nurse should monitor the client's weight and fluid balance and report any sudden or excessive weight gain that may indicate preeclampsia or other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Fundal consistency is correct, as this finding can indicate the effectiveness of oxytocin in stimulating uterine contraction and preventing postpartum hemorrhage. Oxytocin is a uterotonic agent that can enhance or augment uterine contractility and involution. The nurse should monitor the fundal height, consistency, and position and report any signs of uterine atony or excessive bleeding.
Choice B reason: Fetal heart rate is incorrect, as this finding is not relevant for a client who has already delivered the baby. Fetal heart rate can indicate the fetal well-being and response to labor, but it is not affected by oxytocin administration after birth. The nurse should monitor the newborn's vital signs and appearance and report any signs of distress or infection.
Choice C reason: Pulse rate is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Pulse rate can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, fever, or dehydration. The nurse should monitor the client's vital signs and fluid balance and report any signs of shock or infection.
Choice D reason: Urinary output is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Urinary output can indicate the client's renal function and fluid balance, but it can be influenced by many other factors, such as fluid intake, bladder distension, or epidural anesthesia. The nurse should monitor the client's intake and output and report any signs of oliguria or retention.
Choice E reason: Blood pressure is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Blood pressure can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, preeclampsia, or medication. The nurse should monitor the client's vital signs and fluid balance and report any signs of hypotension or hypertension.
Correct Answer is B
Explanation
Choice A reason: Inform the client that she can go to the bathroom whenever needed is incorrect, as this action can put the client at risk of injury or complications. The client may experience orthostatic hypotension, dizziness, weakness, or bleeding after a vaginal birth, which can impair their ability to ambulate safely and independently. The nurse should assist the client to the bathroom and monitor their vital signs and lochia.
Choice B reason: This is the correct action. The nurse should assess the client for any residual effects of analgesia, such as dizziness or unsteadiness, which could increase the risk of falls if the client tries to get up.
Choice C reason: Advise the client to remain in bed for the next few hours is incorrect, as this action can increase the risk of bladder distension, infection, or thrombosis. The nurse should encourage and assist the client to ambulate early and frequently after a vaginal birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.
Choice D reason: While assisting the client is a good approach, it is important to first evaluate her condition to ensure it is safe for her to get out of bed. If she has been assessed and is deemed safe to ambulate, assisting her to the bathroom with support might be appropriate. However, the initial step is to assess her condition.
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