A nurse is reviewing true labor vs false labor with a pregnant client. What statement by the client indicates teaching has been effective?

"In false labor, my contractions can decrease by walking or changing positions"

"In true labor, my contractions will be painless"

"When I'm in true labor, my cervix won't dilate."

"In false labor, I will be able to feel the fetuses presenting part in my pelvis"

Answer and Explanation

The Correct Answer is A

A. "In false labor, my contractions can decrease by walking or changing positions." In false labor, also called Braxton Hicks contractions, the contractions often decrease with activity such as walking or changing positions. This is a key distinction between false and true labor.

B. "In true labor, my contractions will be painless." Contractions in true labor are usually painful and become more intense and regular as labor progresses.

C. "When I'm in true labor, my cervix won't dilate." In true labor, the cervix will dilate progressively. In false labor, there is no cervical dilation.

D. "In false labor, I will be able to feel the fetus's presenting part in my pelvis." In true labor, the fetus descends, and the presenting part may be felt. This is not a characteristic of false labor.

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Correct Answer is B

Explanation

A. Check the fluid with Nitrazine paper. While this test can confirm if the membranes have ruptured, assessing the fetal heart rate (FHR) is more critical to ensure that there is no fetal distress due to umbilical cord prolapse.

B. Assess the FHR. After suspected rupture of membranes, the priority is to assess the fetal heart rate to check for potential complications like umbilical cord prolapse, which can cause fetal distress.

C. Note the color of the fluid. Assessing the color of the fluid is important, especially if meconium is present, but it is secondary to ensuring fetal well-being by assessing the FHR first.

D. Notify the health care provider. The provider should be notified, but the first action should be to assess the fetal heart rate to check for signs of distress.

Correct Answer is ["10"]

Explanation

Using the formula:

Doserequired(mg) ÷ Doseavailable(mg/mL) = Volume(mL)

50 mg ÷ 5 mg/mL = 10 mL

Therefore, the nurse should administer 10 mL of indomethacin.

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A nurse is reviewing true labor vs false labor with a pregnant client. What statement by the client indicates teaching has been effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A laboring patient reports to the nurse that "I think my water just broke!" The first action the nurse should take is:

Correct Answer is B

Explanation

A nurse is preparing to administer indomethacin 50 mg PO. Available is indomethacin oral suspension 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["10"]

Explanation

A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?

What is the most common cause of early decelerations in fetal heart rate?

A nurse is assisting with the admission of a client who is in preterm labor at 30 weeks of gestation and has a new prescription for betamethasone. Which of the following statements should the nurse make?

What is the primary purpose of assessing fetal heart rate patterns during labor and delivery?

A disadvantage of internal fetal monitoring is:

A nurse is assisting with the care of a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

A nurse is assisting 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 confirm that the client is in labor?

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?