Author Question: Which assessment is the best indication that a client is in true labor? a. Bloody show present ... (Read 64 times)

shenderson6 · **on:** Jun 27, 2018

Which assessment is the best indication that a client is in true labor?

a. Bloody show present
b. Nitrazine test positive
c. Vertex presentation at -1 station
d. Cervix 6 centimeters dilated, 100 percent effaced

Question 2

The nurse is administering packed red blood cells to a child with sickle cell disease. The nurse knows that a transfusion reaction is most likely to occur:

1. 6 hours after the transfusion is given.
2. Within the first 20 minutes of administration of the transfusion.
3. At the end of the administration of the transfusion.
4. Never. Blood reactions to transfusions do not occur.

meganmoser117 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

D
Cervical dilation of 6 cm and 100 percent effacement is an indication of the active phase of the first stage of true labor. Bloody show is a sign of impending labor. Nitrazine test positive is a manifestation of amniotic membrane rupture. Vertex presentation at -1 station can occur before labor begins.

Answer to Question 2

2
Rationale:
1. Blood reactions can occur as soon as the blood transfusion begins, or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.
2. Blood reactions can occur as soon as the blood transfusion begins, or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.
3. Blood reactions can occur as soon as the blood transfusion begins, or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.
4. Blood reactions can occur as soon as the blood transfusion begins, or within the first 20 minutes. The nurse should remain with the child for the first 20 minutes of the transfusion.