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A nurse is reinforcing teaching about preterm labor with a client who is at 28 weeks of gestation.Which of the following statements by the client indicates an understanding of the teaching?

A.

“I should expect to feel pain in my upper right abdomen if I’m having preterm labor.”.

B.

“If I have contractions more often than every 10 minutes, I might be in preterm labor.”.

C.

“I can take a daily iron supplement to prevent preterm labor.”.

D.

“I might be experiencing preterm labor if walking stops my contractions.”.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Pain in the upper right abdomen is not a typical sign of preterm labor. Preterm labor symptoms include regular contractions, lower back pain, and pelvic pressure.

 

Choice B rationale

 

Contractions occurring more frequently than every 10 minutes can indicate preterm labor. Regular contractions are a key sign of preterm labor.

 

Choice C rationale

 

While iron supplements are important during pregnancy, they do not prevent preterm labor. Preterm labor is influenced by various factors, including infections and uterine abnormalities.

 

Choice D rationale

 

Walking typically does not stop contractions associated with preterm labor. In fact, activity can sometimes exacerbate contractions.


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Correct Answer is D

Explanation

Choice A rationale

Diuresis, or increased urine production, is not a common adverse effect of nalbuphine hydrochloride. This medication is an opioid analgesic used for pain relief during labor.

Choice B rationale

Fever is not a typical adverse effect of nalbuphine hydrochloride. Fever may indicate an infection or other underlying condition that needs to be addressed separately.

Choice C rationale

Diarrhea is not a common adverse effect of nalbuphine hydrochloride. Opioids, including nalbuphine, are more likely to cause constipation rather than diarrhea.

Choice D rationale

Sedation is a known adverse effect of nalbuphine hydrochloride. As an opioid analgesic, it can cause drowsiness and sedation, which is important to monitor in laboring clients to ensure their safety and well-being.

Correct Answer is B

Explanation

Choice A rationale

Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.

Choice B rationale

Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.

Choice C rationale

Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.

Choice D rationale

Touching the corner of the newborn’s mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the stimulus and open their mouth.

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