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.

Answer and Explanation

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.

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Correct Answer is ["B","E"]

Explanation

Choice A rationale
Abundant lanugo, which is fine hair, is not typically seen in postmature babies. It is more common in babies who are born prematurely.
Choice B rationale
A positive Moro reflex is a normal finding in newborns, including those who are postmature, indicating a healthy neurological response.
Choice C rationale
Vernix, a white creamy substance that protects the baby’s skin in the womb, is usually absent or very scant in postmature babies.
Choice D rationale
Short, soft fingernails are not a specific sign of postmaturity. Newborns’ fingernails can vary, and they often grow quickly after birth.
Choice E rationale

Cracked, peeling skin is commonly seen in postmature babies. Their skin can often appear dry and wrinkled.

A. Eagerness to learn newborn care skills. B. Expressions of excitement. C. Focus on the family unit and its members. D. Lack of appetite.

Correct Answer is B

Explanation

The correct answer is choiceB. Expressions of excitement.

Choice A rationale:

Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase, which follows the “taking-in” phase.During the taking-hold phase, the mother becomes more independent and starts to take an active role in caring for her newborn.

Choice B rationale:

Expressions of excitement are typical during the “taking-in” phase. This phase occurs in the first 1-2 days postpartum, where the mother is primarily focused on herself and her birth experience.She may be excited and talkative about the birth process.

Choice C rationale:

Focus on the family unit and its members is more aligned with the “letting-go” phase, which is the final phase of maternal postpartum adjustment.In this phase, the mother starts to integrate the newborn into the family and adjusts to her new role.

Choice D rationale:

Lack of appetite can occur during the “taking-in” phase due to exhaustion and the physical demands of labor, but it is not a defining characteristic of this phase.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

A nurse is caring for a client who experienced a vaginal birth 12 hours ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?

Correct Answer is B

Explanation

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A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor, which of the following assessment findings should the nurse report to the provider first?

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A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. Which of the following actions should the nurse take if the client’s fingers are tingling?

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client’s oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?