Aureissisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirms that the client is in labor?
Fain just above the navel
Cervical dilation
Amniotic fluid in the vaginal vault
Contractions every 3 to 4 min
The Correct Answer is B
Choice A rationale: Pain above the navel is not a specific indicator of labor and may be unrelated to the onset of labor.
Choice B rationale: Cervical dilation is a definitive sign of labor. It indicates that the cervix is opening to allow the baby's passage through the birth canal.
Choice C rationale: The presence of amniotic fluid in the vaginal vault (rupture of membranes) could indicate that the client's water has broken, but it does not confirm active labor. Labor can begin before or after the rupture of membranes.
Choice D rationale: Regular contractions are a typical sign of labor, but their frequency alone does not confirm active labor. Other signs, such as cervical dilation and effacement, are necessary to confirm active labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: This response assumes that the couple's religious beliefs are relevant to them, which may not be the case. It is not appropriate for the nurse to suggest involving their minister without knowing their preferences or beliefs.
Choice B rationale: This response acknowledges the couple's emotional experience and shows empathy toward their grief. It offers support and reassurance that the nurse will be available to help them through this difficult time.
Choice C rationale: While this statement may be factually true, it is not empathetic or supportive of the couple's current emotional state. It may come across as dismissive of their feelings and minimize their grief.
Choice D rationale: While gathering information about the pregnancy is essential for the medical record, this question does not address the couple's emotional needs. It is more appropriate to focus on offering emotional support and assistance rather than immediately delving into clinical details.
Correct Answer is ["89.722"]
Explanation
To convert ounces to milliliters, we use the conversion factor: 1 oz = 29.5735 mL
0.5 oz = 0.5 * 29.5735 = 14.7868 mL (0800 feedings)
1 oz = 1 * 29.5735 = 29.5735 mL (1100 feeding)
0.5 oz = 0.5 * 29.5735 = 14.7868 mL (1300 feeding)
0.5 oz = 0.5 * 29.5735 = 14.7868 mL (1600 feeding)
0.5 oz = 0.5 * 29.5735 = 14.7868 mL (1830 feeding)
Total intake = 14.7868 + 29.5735 + 14.7868 + 14.7868 + 14.7868 = 89.722 mL
So, the nurse should record 89.722 mL of formula as the client's intake for the shift.
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