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 B
Explanation
Choice A reason: Hematuria is blood in the urine. It is not a symptom of endometritis, which is an inflammation or infection of the uterine lining. Hematuria can have many other causes, such as urinary tract infections, kidney stones, bladder cancer, or trauma.
Choice B reason: Pelvic pain is one of the most common symptoms of endometritis. It can be caused by the inflammation or infection of the uterine lining, which can also spread to other pelvic organs. Pelvic pain can be dull, sharp, cramping, or constant, and it may worsen with movement or intercourse¹³.
Choice C reason: Pink lochia is normal vaginal discharge after childbirth. It consists of blood, mucus, and tissue from the uterus. It usually lasts for a few weeks and gradually changes color from red to pink to brown to white. Pink lochia is not a sign of endometritis, unless it is foul-smelling, heavy, or persists beyond six weeks.
Choice D reason: Bradycardia is a slow heart rate, usually below 60 beats per minute. It is not a symptom of endometritis, which can cause fever and tachycardia (fast heart rate). Bradycardia can have many other causes, such as heart disease, medication side effects, hypothyroidism, or electrolyte imbalance.
Correct Answer is A
Explanation
Choice A reason: Massage the client's fundus is correct, as this is the first action the nurse should take according to the ABCDE priority framework. Saturating a perineal pad in 10 min indicates excessive bleeding and possible postpartum hemorrhage, which can compromise the client's airway, breathing, and circulation. Massaging the fundus can stimulate uterine contraction and reduce blood loss.
Choice B reason: Check the client's blood pressure is incorrect, as this is not the first action the nurse should take, although it is important to monitor for signs of shock. Checking the blood pressure does not address the cause of bleeding or prevent further blood loss.
Choice C reason: Administer oxytocin is incorrect, as this is not the first action the nurse should take, although it may be indicated later. Administering oxytocin requires a provider's order and may have adverse effects such as nausea,
vomiting, headache, or water intoxication. The nurse should first atempt to control bleeding by massaging the fundus and then administer oxytocin as ordered.
Choice D reason: Observe for pooling of blood under the butocks is incorrect, as this is not the first action the nurse should take, although it can help estimate blood loss. Observing for pooling of blood does not address the cause of bleeding or prevent further blood loss. The nurse should first atempt to control bleeding by massaging the fundus and then assess for other signs of hemorrhage.
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