A practical nurse is gathering data on how a client in labor is coping with labor.
Which of the following findings demonstrates the client is coping well?

Rhythmic respirations.

Crying.

Lack of concentration.

Perspiration.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Rhythmic respirations indicate the client is using controlled breathing techniques to manage labor pain, which demonstrates effective coping. This method helps maintain oxygen levels and can reduce the perception of pain through focused breathing.

Choice B rationale

Crying during labor may indicate emotional distress or pain, suggesting the client might be struggling to cope effectively with labor. While it is a natural response, it is not typically associated with controlled coping mechanisms.

Choice C rationale

Lack of concentration can indicate that the client is overwhelmed by pain or anxiety, which may hinder her ability to use coping strategies effectively. It suggests she might be struggling to manage her labor experience.

Choice D rationale

Perspiration is a common physiological response to the exertion and stress of labor, but it does not specifically indicate how well the client is coping with labor pain or stress. It is a normal part of the labor process but not a clear sign of effective coping.

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Correct Answer is A

Explanation

Choice A rationale

Heavy vaginal bleeding at 39 weeks of gestation could be due to placental abruption or placenta previa, which necessitates immediate delivery to prevent maternal and fetal complications. Preparing for cesarean birth is crucial as it allows rapid delivery, reducing the risk of maternal hemorrhage and fetal hypoxia.

Choice B rationale

Performing a cervical examination can exacerbate bleeding in cases of placenta previa or placental abruption, making it unsafe. It can disturb the placenta and lead to further complications, so this option is not recommended.

Choice C rationale

Magnesium sulfate is used to prevent seizures in preeclampsia or eclampsia, not for managing heavy vaginal bleeding. Its use is unrelated to the immediate care of a client with heavy vaginal bleeding due to suspected placental issues.

Choice D rationale

Administering antibiotics is not the immediate priority in the case of heavy vaginal bleeding at 39 weeks of gestation. The focus should be on stabilizing the mother and preparing for delivery.

A. Absent Moro reflex, arm extended at the elbow and positioned against body with decreased grasp on affected side. B. Asymmetry of the face during crying and drooping of the corner of the mouth on affected side. C. Asymmetry of Moro reflex, arm externally rotated, and grasp reflex absent on affected side. D. Asymmetry of Moro reflex, crepitus, no movement, swelling, and tenderness on palpation of affected arm.

Correct Answer is A

Explanation

Choice A rationale

Duchenne-Erb (Erb's) palsy is a type of brachial plexus injury that commonly results in an absent Moro reflex on the affected side, an extended arm at the elbow, and decreased grasp. These symptoms arise from injury to the fifth and sixth cervical nerves, leading to motor deficits.

Choice B rationale

This describes facial nerve palsy, not Erb's palsy. Facial nerve palsy affects the muscles of the face, leading to asymmetry during crying and drooping of the mouth's corner on the affected side.

Choice C rationale

While asymmetry of the Moro reflex is accurate, this choice incorrectly states that the arm is externally rotated and the grasp reflex is absent, which aligns more with a total brachial plexus injury rather than Erb's palsy.

Choice D rationale

Crepitus, no movement, swelling, and tenderness on palpation are indicative of a fracture rather than Erb's palsy. These symptoms suggest bone injury rather than nerve damage.

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A practical nurse is gathering data on how a client in labor is coping with labor. Which of the following findings demonstrates the client is coping well?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data on a newborn who has experienced Duchenne-Erb (Erb's) palsy. Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse take?

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A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

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A practical nurse is gathering data on how a client in labor is coping with labor.
Which of the following findings demonstrates the client is coping well?