which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor

HESI LPN

HESI Focus on Maternity Exam

1. Which statement by the client will assist the healthcare provider in determining whether she is in true labor as opposed to false labor?

A. I passed some thick, pink mucus when I urinated this morning.
B. My bag of waters just broke.
C. The contractions in my uterus are getting stronger and closer together.
D. My baby dropped, and I have to urinate more frequently now.

Correct answer: C

Rationale: The correct answer is C. Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Choice A indicates the passing of the mucus plug, which is a sign of early labor but not definitive for true labor. Choice B, the breaking of the bag of waters, is a sign of labor but does not confirm whether it is true or false labor. Choice D, the baby dropping and increased urination frequency, suggests lightening, a sign that labor may be approaching, but it does not confirm true labor.

2. Which of the following statements is true about Tay-Sachs disease?

A. It is most commonly found among children in Jewish families of Eastern European background.
B. Children who have this disease suffer from excessive production of mucus in the lungs and pancreas.
C. It is most commonly found among children in Asian American families.
D. Children who have this disease suffer from muscular dystrophy characterized by a weakening of the muscles.

Correct answer: A

Rationale: The correct answer is A. Tay-Sachs disease is most commonly found among Jewish families of Eastern European descent. It is a fatal genetic disorder that affects the nervous system. Choice B is incorrect because Tay-Sachs disease does not involve excessive mucus production in the lungs and pancreas. Choice C is incorrect as it states that Tay-Sachs disease is most commonly found among Asian American families, which is inaccurate. Choice D is also incorrect because Tay-Sachs disease does not cause muscular dystrophy characterized by weakening of the muscles.

3. Individuals with Klinefelter syndrome produce:

A. less estrogen than normal males.
B. less testosterone than normal males.
C. less adenine than normal males.
D. less thymine than normal males.

Correct answer: B

Rationale: Individuals with Klinefelter syndrome have an extra X chromosome (XXY), leading to reduced production of testosterone, the primary male sex hormone. This deficiency can result in various physical and developmental characteristics associated with the syndrome. Estrogen levels may actually be relatively elevated due to the imbalance between testosterone and estrogen. Choices C and D are incorrect as adenine and thymine are nucleotide bases found in DNA and are not related to hormone production.

4. A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman’s vital signs, which finding would be of greatest concern to the nurse?

A. Temperature 37.9°C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg.
B. Temperature 37.4°C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg.
C. Temperature 38°C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg.
D. Temperature 36.8°C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg.

Correct answer: A

Rationale: An estimated blood loss (EBL) of 1500 ml following a vaginal birth is significant and can lead to hypovolemia. The vital signs provided in option A (Temperature 37.9°C, heart rate 120 bpm, respirations 20 breaths per minute, and blood pressure 90/50 mm Hg) indicate tachycardia and hypotension, which are concerning signs of hypovolemia due to excessive blood loss. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased blood volume, and hypotension indicates inadequate perfusion. Options B, C, and D do not exhibit the same level of concern for hypovolemia. Option B shows tachypnea, which can be a result of pain or anxiety postpartum. Option C and D have vital signs within normal limits, which are not indicative of the body's response to significant blood loss.

5. A client is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?

A. Increase the infusion rate every 30 to 60 minutes.
B. Maintain the client in a supine position.
C. Titrate the infusion rate by 4 milliunits/min.
D. Limit IV intake to 4 L per 24 hours.

Correct answer: A

Rationale: The correct answer is to increase the infusion rate every 30 to 60 minutes. This approach allows for the careful monitoring and adjustment of oxytocin administration during labor induction. Choice B is incorrect because maintaining the client in a supine position can decrease blood flow to the placenta and compromise fetal oxygenation. Choice C is incorrect as titrating the infusion rate by 4 milliunits/min is not a standard practice for oxytocin administration. Choice D is incorrect as limiting IV intake to 4 L per 24 hours is not specifically related to the administration of oxytocin for labor induction.