A nurse is attending to a client who is a first-time mother, at term, and experiencing contractions. She is uncertain if she is in labor.Which of the following would the nurse identify as an indication of true labor?
Pattern of contractions.
Rupture of the membranes.
Position of the presenting part.
Changes in the cervix.
The Correct Answer is A
Choice A rationale
This is the correct answer. Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor.
Choice B rationale
Rupture of the membranes can occur before or during labor, but it is not a definitive sign of true labor.
Choice C rationale
The position of the presenting part is not a definitive sign of true labor.
Choice D rationale
Changes in the cervix can be a sign of true labor, but without regular, strong contractions, it is not a definitive sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Step 1 is to determine the amount of heparin to administer. The client is receiving 3,800 units of heparin, and the available heparin is 5,000 units/mL.
Step 2 is to set up the calculation: (3,800 units ÷ 5,000 units/mL) = x mL.
Step 3 is to perform the calculation: x = 0.76 mL. Therefore, the nurse should administer 0.8 mL of heparin, rounded to the nearest tenth.
Correct Answer is C
Explanation
Choice A rationale
Placing a newborn under a radiant heat warmer after birth does not directly prevent basal metabolic rate reduction. The primary function of a radiant heat warmer is to maintain the newborn’s body temperature and prevent hypothermia.
Choice B rationale
While brown fat production is a mechanism used by newborns to generate heat, placing a newborn under a radiant heat warmer does not stimulate brown fat production.
Choice C rationale
The primary purpose of placing a newborn under a radiant heat warmer after birth is to maintain the newborn’s body temperature. Newborns can lose heat rapidly, as they have a
large surface area compared to their body weight. The radiant heat warmer provides a controlled environment that helps maintain the newborn’s body temperature.
Choice D rationale
Preventing hypothermia is a key reason for placing a newborn under a radiant heat warmer. However, the direct purpose of the warmer is to maintain the newborn’s body temperature.
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