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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Acyclovir is an antiviral medication used primarily to treat herpes simplex virus (HSV) infections to prevent vertical transmission to the neonate. Group B Streptococcus (GBS) is a bacterium and is treated with antibiotics, specifically penicillin or ampicillin, administered intravenously during labor and delivery to prevent neonatal sepsis.
Choice B rationale
The Group B Streptococcus (GBS) culture is typically collected as a single screen between 36 weeks 0 days and 37 weeks 6 days of gestation from the lower vagina and perirectal area. This one-time positive result is sufficient to indicate the need for intrapartum antibiotic prophylaxis (IAP); repeat testing 24 hours later is not standard practice.
Choice C rationale
If the Group B Streptococcus (GBS) culture is positive, the client is considered colonized and requires intrapartum antibiotic prophylaxis (IAP), usually penicillin G, administered intravenously at the onset of labor or rupture of membranes. This reduces the risk of GBS transmission to the newborn, which can cause severe neonatal morbidity like sepsis or pneumonia.
Choice D rationale
The Group B Streptococcus (GBS) culture is a screening test obtained via a swab of the client's lower vagina and perirectal area, not a blood test. The GBS bacteria colonize these areas, and the swab is sent for culture and sensitivity to determine the need for prophylactic antibiotics during labor.
Correct Answer is A
Explanation
Choice A rationale
Soft grunting noises during expiration are a sign of mild to moderate respiratory distress in a newborn. Grunting is the newborn's attempt to keep the alveoli open by increasing Positive End-Expiratory Pressure (PEEP), suggesting decreased lung compliance or insufficient surfactant. This finding requires immediate notification of the provider for evaluation and potential intervention.
Choice B rationale
A positive Babinski reflex, which involves the great toe dorsiflexing and the other toes fanning out upon stroking the sole of the foot, is a normal neurological finding in a newborn and infant. This reflex persists until about 1 to 2 years of age as the central nervous system matures, and therefore does not require reporting.
Choice C rationale
Acrocyanosis, which is pale blue hands and feet with pinkish trunk and mucous membranes, is a common and normal finding in a newborn during the first 24 to 48 hours after birth due to immature peripheral circulation and cold exposure. This peripheral vasoconstriction resolves spontaneously and is not typically reported unless accompanied by central cyanosis.
Choice D rationale
Blood-tinged discharge from the vagina, often called pseudomenstruation, is a normal, transient finding in female newborns. It is caused by the withdrawal of maternal estrogen hormones following birth, leading to a minor sloughing of the uterine endometrium, and does not indicate a pathological condition requiring immediate reporting.
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