The Labor and delivery triage nurse is assessing a primigravida at 38 weeks and 3 days gestation who reports uterine contractions that started 2 hours ago. Further examination reveals a cervix that is dilated at 1 cm and 20% effaced with intact membranes. What action will the nurse implement?

Inform the patient that they are in latent Labor.

Initiate Labor augmentation.

Prepare the patient for a caesarean delivery.

Anticipate admission to the Labor and delivery unit.

Answer and Explanation

The Correct Answer is A

Choice A reason: Informing the patient that they are in latent Labor is appropriate in this situation. Latent Labor, also known as early Labor, is characterized by cervical dilation of up to 3 cm and mild contractions that may last for several hours or even days. It is important to educate the patient about the early stages of Labor and what to expect as it progresses.

Choice B reason: Initiating Labor augmentation is not necessary at this point. Labor augmentation is typically used when Labor is not progressing adequately. In this case, the patient is in the early stages of Labor, and there is no indication that augmentation is needed.

Choice C reason: Preparing the patient for a caesarean delivery is not warranted based on the information provided. The patient's condition does not suggest any immediate need for a caesarean section, and the Labor is still in its early stages.

Choice D reason: Anticipating admission to the Labor and delivery unit may not be required at this stage. Since the patient is in latent Labor, they may be advised to stay at home until Labor progresses further and the contractions become more intense and frequent. This helps reduce unnecessary hospital admissions and allows the patient to be more comfortable in their home environment.

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Correct Answer is B

Explanation

Choice A reason: Human papillomavirus (HPV) is a separate infection that is not a direct complication of untreated chlamydia. While both are sexually transmitted infections, they have different causative agents and manifestations.

Choice B reason: Pelvic inflammatory disease (PID) is a serious complication that can arise from untreated chlamydia. PID can lead to severe reproductive health issues, including chronic pelvic pain, ectopic pregnancy, and infertility. Monitoring and treating chlamydia is crucial to prevent the development of PID.

Choice C reason: Cardiac arrhythmias are not a known complication of chlamydia. This condition pertains to abnormal heart rhythms, which are unrelated to the infection caused by chlamydia.

Choice D reason: Extreme weight loss is not directly associated with chlamydia infection. While untreated chlamydia can have significant health impacts, extreme weight loss is not a typical complication of this disease.

A. The baby will eat on a schedule of every two to three hours for at least 15 minutes. B. Do not wake them for feeding. Never wake a sleeping baby. C. I will feed my baby when they start smacking their lips or sucking on their hands. D. It is important for a baby to cry. If I respond too soon, they will be spoiled.

Correct Answer is C

Explanation

Choice A reason: This statement suggests a rigid schedule for feeding, which may not always align with an infant's natural hunger cues. While some babies may follow a regular feeding pattern, it's essential to prioritize the baby's hunger cues over a strict schedule. Feeding on demand, when the baby shows signs of hunger, is generally recommended to ensure they receive adequate nutrition and comfort.

Choice B reason: Advising not to wake a sleeping baby for feeding is not accurate for all situations. Newborns, especially in the first few weeks, may need to be woken for feeding if they are not gaining weight adequately or if they have medical conditions that require regular feeding. It is important to balance letting the baby sleep and ensuring they get enough nutrition, particularly in the early stages.

Choice C reason: Feeding the baby when they start smacking their lips or sucking on their hands demonstrates an understanding of responding to hunger cues. These behaviours are early signs of hunger, and feeding the baby at this stage can prevent them from becoming overly hungry and fussy. This approach aligns with best practices for feeding on demand, promoting healthy growth and development.

Choice D reason: This statement reflects a misunderstanding of infant care. Crying is a late sign of hunger, and it is important to respond to early hunger cues to prevent distress. The idea that responding too soon to a baby's needs will spoil them is a myth. Timely and responsive care fosters a sense of security and trust in the caregiver-infant relationship, contributing to the baby's overall well-being.

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The Labor and delivery triage nurse is assessing a primigravida at 38 weeks and 3 days gestation who reports uterine contractions that started 2 hours ago. Further examination reveals a cervix that is dilated at 1 cm and 20% effaced with intact membranes. What action will the nurse implement?

Nursing Test Bank

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Explanation

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Correct Answer is C

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