The nurse is assessing a laboring patient. Which specific behavior(s) or sign(s) indicate(s) that birth is imminent? (Select all that apply.)
a. Involuntarily bearing down with contractions
b. Bulging of the perineum
c. Grunting sounds
d. The desire to walk around
e. Requests for food and drink
ANS: A, B, C
Sitting on one buttock, making grunting sounds, involuntarily bearing down with contractions, stating "the baby is coming," bulging of the perineum; as the fetal head descends, the woman has the urge to push because of pressure of the head on the sacral nerves and rectum. The perineum begins to bulge and flatten, and crowning occurs.
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While reviewing the bones in anatomy class, the instructor discusses this type of bone that protects the underlying structures. A good example of a flat bone is:
A) metatarsal bones. B) vertebrae. C) femur. D) skull.
A client admitted with nephrolithiasis complains of flank pain
The nurse understands that the client's stone is most likely located in the renal pelvis and calyces because the client describes the nature of the pain as: Select all that apply: 1. Dull. 2. Constant. 3. Severe. 4. Colicky. 5. Intermittent. Correct
A nurse enters a client's room and finds the client and family member visiting very upset and crying. What is the best response by the nurse to the client and family member at this time?
A) "Would you like me to come back later?" B) "Well, it is raining outside today. Do you want me to close or open the curtains for you?" C) "Has your primary care provider been in to answer your questions today?" D) "You both look very upset. Is there anything you would like to talk about?"