The clinic nurse instructs a group of pregnant women that which sign(s) may alert them to approaching labor? (Select all that apply.)
a. Lightening
b. Bloody show
c. Decreased energy level
d. Decreasing Braxton-Hicks contractions
e. Spontaneous rupture of membranes
ANS: A, B, E
Signs of approaching labor can include lightening, bloody show, energy spurt ("nesting behavior"), increased Braxton-Hicks contractions (false labor), and spontaneous rupture of membranes. (Cervical changes also occur, but a woman may not be aware of them.) Any of these signs may indicate that labor is likely to occur soon. With the exception of a rupture of membranes, it may not be necessary for the woman to consult her health care provider when these events happen.
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A nurse teaches a client who has been prescribed a 24-hour urine collection to measure excreted hormones. The client asks, "Why do I need to collect urine for 24 hours instead of providing a random specimen?" How should the nurse respond?
a. "This test will assess for a hormone secreted on a circadian rhythm." b. "The hormone is diluted in urine; therefore, we need a large volume." c. "We are assessing when the hormone is secreted in large amounts." d. "To collect the correct hormone, you need to urinate multiple times."
The nurse is doing a neurologic assessment on a 2-month-old infant after a car accident. Moro, tonic neck, and withdrawal reflexes are present. How should the nurse interpret these findings?
a. Neurologic health b. Severe brain damage c. Decorticate posturing d. Decerebrate posturing
A client has a long leg cast as a result of a fractured femur. Which of the following findings would indicate adequate circulation is occurring in the limb?
1. No evidence of edema of the toes or change in sensation 2. Drainage on the cast 3. Increased temperature 4. Cast emitting foul odor
The nurse requests a dietary consult to address the patient's high rate of catabolism. Which nutritional element is directly related to this metabolic process?
a. Carbohydrates b. Proteins c. Liquids d. Fats