A 35-week infant is admitted to the NICU with a diagnosis of preterm with respiratory distress syndrome. The nurse observes that the client will stop breathing for 20-30 seconds then resume breathing. The nurse documents this as:

Correct Answer: A

Rationale: Periodic breathing is the correct answer in this scenario. Periodic breathing is a normal respiratory pattern in premature infants where they have short episodes of apnea followed by rapid breathing. In this case, the infant stopping breathing for 20-30 seconds then resuming breathing aligns with the definition of periodic breathing. This pattern is commonly seen in premature infants and usually resolves on its own as the infant matures. Apneic breathing (choice B) refers to a more prolonged cessation of breathing and is not characteristic of the brief episodes seen in periodic breathing. Apneic breathing is a cause for concern and may require intervention to support the infant's breathing. Grunting (choice C) is a sound made by infants during expiration to help keep the lungs inflated. While grunting may be present in infants with respiratory distress syndrome, it does not describe the pattern of breathing observed in this case. Neonatal dyspnea (choice D) refers to difficulty breathing in a newborn, which can present with a variety of symptoms such as grunting, nasal flaring, and retractions. While respiratory distress syndrome can lead to neonatal dyspnea, the specific breathing pattern described in the question is better classified as periodic breathing.

Correct Answer: D

Rationale: During the second stage of labor, the cervix is fully dilated, and the woman is ready to push the baby out. Option D, taking a slow cleansing breath before bearing down, is the correct choice because it helps the woman gather energy and focus before pushing. This breath helps prevent hyperventilation and provides the woman with the necessary oxygen to push effectively. Option A, holding her breath for twenty seconds during every contraction, is incorrect because holding the breath for too long can decrease oxygen levels to the baby and increase the woman's risk of hyperventilation and dizziness. This can lead to decreased effectiveness in pushing and potential harm to both the mother and the baby. Option B, blowing out forcefully during every contraction, is also incorrect because blowing out forcefully may reduce the woman's ability to push effectively. It can also cause the woman to waste energy and may not provide the necessary force to move the baby down the birth canal. Option C, pushing between contractions until the fetal head is visible, is incorrect because pushing between contractions can lead to exhaustion and may not be as effective as pushing during contractions. It is important for the woman to conserve energy and push during contractions when the uterus is actively working to move the baby down.

Correct Answer: B

Rationale: During the third stage of labor, the correct chronological order of physiological changes is as follows: B: Membranes separate from the uterine wall - This is the correct answer because during the third stage of labor, the placenta detaches from the uterine wall, and the amniotic sac is expelled. Now, let's discuss why the other choices are incorrect: A: Hematoma forms behind the placenta - This choice is incorrect because the formation of a hematoma typically occurs due to trauma or injury and is not a normal physiological change during the third stage of labor. C: The uterus contracts firmly - This choice is incorrect because uterine contractions typically occur during the first and second stages of labor to help push the baby out. In the third stage, the focus is on delivering the placenta, not on uterine contractions. D: The uterine surface area dramatically decreases - This choice is incorrect because the uterus does not decrease in size during the third stage of labor. After the delivery of the placenta, the uterus will continue to contract to help control bleeding and return to its pre-pregnancy size over time.

Correct Answer: A

Rationale: During the active phase of labor, a client is typically focused on coping with contractions and may not be as talkative or happy. Therefore, if a client in labor is talkative and happy, it suggests that they are likely in the early phase of labor, specifically the latent phase. Choice A: 2 cm dilation is the correct answer in this scenario because it aligns with the behavior of being talkative and happy. At 2 cm dilation, contractions are usually mild and irregular, allowing the client to converse and maintain a positive mood. Choice B: 4 cm dilation is in the active phase of labor, where contractions become more intense and frequent. Clients at this stage are usually more focused on coping with the discomfort and may not be as talkative or happy. Choice C: 8 cm dilation indicates that the client is in the transition phase, which is characterized by intense contractions and often overwhelming sensations. Clients at this stage are typically focused on labor and may not be talkative or happy. Choice D: 10 cm dilation represents full dilation and is the start of the pushing stage. At this point, the client is usually focused on the pushing efforts and the imminent arrival of the baby, rather than being talkative and happy. In summary, based on the client's behavior of being talkative and happy, the most likely dilation would be 2 cm as it corresponds to the latent phase of labor where contractions are mild and irregular, allowing the client to engage in conversation and maintain a positive mood.

Correct Answer: B

Rationale: B: Phenergan (promethazine) is the correct answer. Promethazine is commonly used as an analgesic-potentiating medication in combination with opiates to enhance their pain-relieving effects. It acts as an adjunctive therapy by reducing nausea and vomiting, which can commonly occur with opiate use. This combination helps improve patient comfort and satisfaction during labor. A: Seconal (secobarbital) is incorrect because it is a barbiturate, not an analgesic-potentiating medication. Barbiturates are not typically used in combination with opiates for pain management during labor due to their sedative effects and potential for respiratory depression. C: Benadryl (diphenhydramine) is incorrect because it is an antihistamine, not an analgesic-potentiating medication. While Benadryl can have sedative effects and may be used for nausea or itching, it is not commonly used to enhance the effects of opiates for pain relief during labor. D: Tylenol (acetaminophen) is incorrect because it is not an analgesic-potentiating medication. Acetaminophen is a mild pain reliever often used for mild to moderate pain, but it does not potentiate the effects of opiates. It is not typically used in combination with opiates for pain management during labor.