A nurse is assessing a client who is at 38 weeks of gestation.
Upon admission 2 hours ago, the client had irregular contractions, was dilated 2 cm, and was at -1 cm station. Which of the following findings indicates progression in labor?
The client's contractions persist with walking.
The client reports urinary frequency.
The client has increased blood-tinged vaginal mucus.
The client's station is at -3 cm.
The Correct Answer is A
Choice A rationale
True labor contractions persist and often intensify with activity, such as walking, because physical exertion promotes the release of oxytocin. In contrast, Braxton Hicks or false labor contractions typically diminish or cease with ambulation. Therefore, contractions persisting with walking indicate the cervical changes characteristic of progression into the active phase of labor.
Choice B rationale
Urinary frequency is a common discomfort throughout the third trimester of pregnancy due to the pressure of the enlarged uterus on the bladder. While present, it is not a specific indicator of the progression of labor from the latent to the active phase, which is characterized by measurable changes in cervical dilation and effacement.
Choice C rationale
Increased blood-tinged vaginal mucus, known as "bloody show," results from the cervical capillaries breaking as the cervix effaces and dilates. While this indicates cervical change, the most definitive sign of labor progression is a change in the frequency, duration, and intensity of contractions coupled with measurable descent or cervical dilation increase.
Choice D rationale
The station is the relationship of the presenting part to the ischial spines (zero station). The client's initial station was -1 cm. A change to -3 cm station indicates the fetus has moved up and away from the ischial spines, which signifies regression, or higher negative numbers, in the engagement, not the desired progression into the maternal pelvis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Initiating internal fetal heart rate monitoring is an invasive procedure that is not the priority for a non-reassuring fetal heart rate pattern like late decelerations, which often indicate uteroplacental insufficiency. The first step involves non-invasive intrauterine resuscitation measures to immediately improve fetal oxygenation before considering invasive monitoring, unless the external tracing is inadequate.
Choice B rationale
Late decelerations are an indication of uteroplacental insufficiency (decreased blood flow/oxygen to the fetus during the contraction). Assisting the client to a left lateral position is the priority nursing action because it relieves pressure from the gravid uterus on the vena cava, which in turn maximizes venous return to the heart and increases blood flow and oxygen delivery to the placenta and fetus.
Choice C rationale
While uterine tachysystole (excessive frequency of contractions, greater than five in 10 minutes over 30 minutes) can cause late decelerations, palpating for it is not the absolute first action. The immediate priority is to improve fetal oxygenation by repositioning the mother. Palpation for tachysystole, however, is a quick assessment that should follow the repositioning intervention.
Choice D rationale
Increasing the infusion rate of the maintenance IV fluid (an IV fluid bolus) is a critical step in intrauterine resuscitation for late decelerations. It increases maternal blood volume, which can improve placental perfusion. However, repositioning the client is generally the most immediate, least invasive, and first step to correct or improve the blood flow to the placenta and fetus.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Consistent crying is considered a late cue of hunger in a newborn. Crying, a complex physiological and behavioral response, requires a high expenditure of energy and is an indication that the newborn is already significantly distressed by hunger and needs to be fed immediately to avoid excessive agitation and difficulty latching.
Choice B rationale
The rooting reflex involves the newborn turning their head toward any stimulation of their cheek or mouth and opening their mouth, which is an innate physiological response critical for locating the nipple. This is a primary early hunger cue, indicating the newborn is ready and searching for a food source, initiating feeding efforts.
Choice C rationale
Sucking motions, such as rapid, repetitive sucking on the lips, tongue, or anything near the mouth, are direct early behavioral manifestations of the newborn's innate physiological need for nourishment. This action is a preparatory step for feeding, indicating readiness for oral intake and satiation of hunger.
Choice D rationale
Hand-to-mouth movements are a key early hunger cue, demonstrating the newborn's increasing drive to seek oral stimulation and food. This behavior is part of the newborn's reflexive self-soothing and exploratory repertoire, signaling a rising level of hunger before the onset of overt distress or crying.
Choice E rationale
The Babinski reflex is a normal neurological response in infants where the great toe extends upward and the other toes fan out when the sole of the foot is firmly stroked. It is a primitive reflex related to neurological development and is not an indicator of hunger or feeding readiness.
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