A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

Intense contractions lasting 45 to 60 seconds.

An urge to have a bowel movement during contractions.

A sense of excitement and warm, flushed skin.

Progressive sacral discomfort during contractions.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Intense contractions lasting 45 to 60 seconds are normal during labor.
Choice B rationale:
An urge to have a bowel movement during contractions could indicate that the baby’s head is descending into the birth canal, which may require immediate attention.
Choice C rationale:
A sense of excitement and warm, flushed skin are normal emotional and physiological responses during labor.
Choice D rationale:
Progressive sacral discomfort during contractions is a normal part of labor as the baby descends through the birth canal.

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Correct Answer is B

Explanation

Choice A rationale:
Subcutaneous injections are not typically used for newborns due to their lack of subcutaneous fat.
Choice B rationale:
The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and location.
Choice C rationale:
The deltoid is not a recommended site for IM injections in newborns due to its small size.
Choice D rationale:
As mentioned earlier, subcutaneous injections are not typically used for newborns.

A. "I should avoid breastfeeding for 2 weeks following the immunization.”. B. "I will receive a series of three immunizations and each one will be a month apart.”. C. "I will report joint pain that develops after the immunization to my provider immediately.”. D. "I should avoid becoming pregnant for at least 1 month following the immunization.”.

Correct Answer is D

Explanation

Choice A rationale:
Breastfeeding is not contraindicated following rubella immunization, so this statement is incorrect.
Choice B rationale:
The rubella vaccine is a single-dose vaccine, not a series of three.
Choice C rationale:
Joint pain can occur following rubella immunization, but it’s not a severe side effect that requires immediate medical attention.
Choice D rationale:
Women are advised to avoid pregnancy for at least 1 month following rubella immunization due to the theoretical risk to the fetus, so this statement is correct.

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A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer phytonadione 0.5 mg to a newborn. Which of the following routes should the nurse choose for administration of the medication?

Correct Answer is B

Explanation

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

Correct Answer is D

Explanation

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