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A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor?

A.

Slow change in dilation and effacement

B.

Contraction intensity increased by ambulation

C.

Presence of bloody show

D.

Intermittent, painless contractions

Answer and Explanation

The Correct Answer is D

Rationale:

A. Slow change in dilation and effacement: Even slow cervical changes are indicative of true labor. False labor does not cause any progressive cervical dilation or effacement, making this an inconsistent finding for false labor.

B. Contraction intensity increased by ambulation: In true labor, contractions typically intensify with activity such as walking. In contrast, false labor contractions often diminish or resolve with changes in position or ambulation.

C. Presence of bloody show: Bloody show results from cervical dilation and the disruption of cervical capillaries. It is a hallmark of true labor and would not be expected during false labor.

D. Intermittent, painless contractions: False labor is characterized by irregular, non-progressive, and typically painless contractions, often referred to as Braxton Hicks contractions. These are normal in late pregnancy but do not indicate true labor.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Rationale:

  • Hypercapnia: This is a hallmark of malignant hyperthermia (MH), resulting from uncontrolled calcium release in muscle cells leading to increased metabolism and CO2 production. It is not typical of latex allergy or hypovolemic shock. Neither condition causes increased carbon dioxide retention from muscle metabolism.
  • Tachycardia: Elevated heart rate is common in MH due to hypermetabolic state, in latex allergy as part of anaphylaxis response, and in hypovolemic shock as a compensatory mechanism for decreased circulating volume.
  • Wheezing: Wheezing reflects bronchospasm, a common feature of latex allergy/anaphylaxis, but is not a symptom of MH or hypovolemic shock.
  • Urticaria (hives): Urticaria is a typical allergic skin reaction seen in latex allergy but is absent in MH and hypovolemic shock.
  • Muscle rigidity: Muscle rigidity, particularly jaw muscle rigidity (masseter spasm), is a classic sign of MH due to abnormal muscle metabolism. This finding is not associated with latex allergy or hypovolemic shock.

Correct Answer is B

Explanation

Rationale:

A. Disenfranchised: Disenfranchised grief occurs when the person's mourning is not socially recognized or supported, such as grieving an ex-partner or a stigmatized relationship. In this scenario, the grief is acknowledged and expected, making this option less appropriate.

B. Anticipatory: Anticipatory grief happens when individuals begin mourning a loss before it occurs, as in terminal illness. The family member’s struggle with “letting her go” reflects emotional processing of an expected death before it happens.

C. Delayed: Delayed grief is a postponed emotional response to a loss, often surfacing long after the event. Since the family member is currently expressing emotional difficulty, this is not an example of delayed grief.

D. Exaggerated: Exaggerated grief is intense, overwhelming, and can impair functioning. It may include suicidal ideation or severe depression. The statement indicates sadness and difficulty coping, but not extreme or dysfunctional symptoms.

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