NU 335- exam 3 questions

A low-risk 38-week-gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucus plug." 4. "How much blood is there?"

2. "You sound frightened." The nurse is using reflection to acknowledge the client's concerns. (The nurse must acknowledge that fear before asking other questions or making other comments)

. The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2. Once the cervix begins to dilate, a client is in true labor Although laboring women experience contractions, contractions alone are not an indicator of true labor. Only when the cervix begins to dilate is the client in true labor. False labor contractions are usually irregular and mild, but, in some situations, they can appear to be regular and can be quite uncomfortable.

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap."

3 "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." As labor progresses, the frequency of contractions decreases but the duration and the intensity, or strength, of the contractions increase.

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the client who makes which of the following statements needs additional teaching? 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucus plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina."

3. Expelling the mucus plug is not suffi- cient reason to go to the hospital to be assessed. The mucus plug protects the uterine cavity from bacterial invasion. It is expelled shortly before or during the early phase of labor. But, since the client is exhibiting no other signs of labor, there is no need for the client to go to the hospital for assessment.

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

4 . This client is exhibiting clear signs of true labor. Not only are the contractions lasting a full minute but she is stating that they are so uncomfortable that she is unable to speak through them. She should be seen. remember that nurses interpret the comments made by gravid women who are close to term. Clients, especially primiparas, are often anxious about the labor process and have difficulty interpreting what they are feeling. Only when the woman is experiencing contractions that are increasing in intensity and duration and decreasing in frequency or has ruptured membranes should she be encouraged to go to the hospital for an evaluation.

A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period

4 Contractions lasting 1 minute followed by a 120-second rest period The frequency and duration of this contraction pattern is every 3 minutes lasting 60 seconds.