A client who is primiparous at 40 weeks of gestation calls the labor and delivery unit to ask about coming in to be evaluated for labor. The client reports having contractions every 6 to 8 min, which feels slightly painful. Which of the following questions should the nurse ask the client next?

"Have you had any health concerns during your pregnancy?"

Do have a support person present?"

Have you noticed any fluid leaking from your vagina?"

When was your last prenatal visit?

Answer and Explanation

The Correct Answer is C

A) "Have you had any health concerns during your pregnancy?"
While it's important to assess the client's overall health and pregnancy history, this question doesn't directly address the current concern of possible labor and does not immediately help assess the client's status for labor evaluation. The focus should be on signs of labor or complications at this point.

B) "Do you have a support person present?"
Although this is a helpful question to ask in preparation for labor, it doesn't provide the necessary information needed to assess whether the client is in labor. The priority at this stage is determining if the client is in labor or experiencing any complications, such as rupture of membranes.

C) "Have you noticed any fluid leaking from your vagina?"
This is the most important question to ask next. If the client has ruptured membranes (i.e., water breaking), it is important to assess the timing and nature of the fluid leakage, as it would indicate the need for immediate evaluation at the hospital. Rupture of membranes requires monitoring for infection and should prompt the client to come in for assessment regardless of the frequency or intensity of contractions.
D) "When was your last prenatal visit?"
While it is helpful to know when the client had their last prenatal visit, this question does not directly address the issue of possible labor. The priority is to determine if the client is in labor, whether their membranes have ruptured, or if there are any other complications such as bleeding or abnormal fetal movement. The question about fluid leakage is more immediate and relevant to their current condition.

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Correct Answer is B

Explanation

A) Category I:
Category I fetal heart rate patterns are considered normal and are characterized by a baseline fetal heart rate of 110–160 beats per minute, moderate variability, and the presence of accelerations. The pattern also lacks concerning decelerations. While this client’s fetal heart rate is within the normal baseline range (150 bpm), the presence of occasional variable decelerations indicates that the fetal heart rate pattern does not meet the criteria for Category I.

B) Category II:
Category II includes all fetal heart rate patterns that are not classified as Category I or III. This category represents indeterminate or concerning patterns, which require ongoing assessment and interventions. In this case, the fetal heart rate pattern includes a baseline within the normal range, moderate variability, accelerations, but also occasional variable decelerations. Variable decelerations, particularly when they occur intermittently, are often considered non-reassuring but not immediately concerning if they resolve quickly, placing the pattern in Category II.

C) Uncategorized:
"Uncategorized" refers to situations where the fetal heart rate pattern cannot be classified due to insufficient information or an unclear pattern. This is not applicable here because the nurse has identified sufficient data to classify the pattern.

D) Category III:
Category III patterns are considered abnormal and require prompt intervention. These patterns are characterized by persistent decelerations, such as late decelerations, bradycardia, or variable decelerations that do not resolve with interventions. Since the variable decelerations in this case are occasional and not persistent or severe, this pattern does not meet the criteria for Category III.

A. Uterine contractions B. The fetal head applying pressure C. Nerve stimulation D. Cervical dilation

Correct Answer is B

Explanation

A) Uterine contractions:
While uterine contractions cause significant pain and discomfort during labor, particularly in the first and early second stages, by the time the client reaches the second stage of labor, the cervix is fully dilated, and the main cause of pain and pressure is no longer from the contractions themselves. Instead, the pain and pressure described in the second stage are primarily due to the fetal head descending through the birth canal, applying pressure to the perineum.

B) The fetal head applying pressure:
The pain and pressure reported in the second stage of labor are primarily due to the fetal head descending into and through the birth canal, putting pressure on the cervix, vagina, perineum, and pelvic floor. This pressure is a major source of discomfort in the second stage, as the fetal head stretches the tissues of the perineum, which is essential for facilitating birth. The sensation of pressure on the pelvic floor is often described by clients during this stage.

C) Nerve stimulation:
Nerve stimulation occurs during labor as a result of uterine contractions and the fetal descent, which can cause radiating pain to the lower back, thighs, and pelvic region. However, the specific pain and pressure in the pelvis and perineum described by the client are more directly related to the fetal head applying pressure, rather than generalized nerve stimulation. Nerve stimulation may contribute to pain but is not the primary cause of the pelvic and perineal pressure at this stage.

D) Cervical dilation:
Cervical dilation occurs in the earlier stages of labor (latent and active phases), and while it contributes to pain during these stages, by the second stage, the cervix should be fully dilated (10 cm). The pain and pressure that the client is feeling in the second stage are less about cervical dilation and more about the descent of the fetal head through the birth canal and its pressure on the perineum and pelvic floor.

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A client who is primiparous at 40 weeks of gestation calls the labor and delivery unit to ask about coming in to be evaluated for labor. The client reports having contractions every 6 to 8 min, which feels slightly painful. Which of the following questions should the nurse ask the client next?

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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