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?
Slow change in dilation and effacement
Contraction intensity increased by ambulation
Presence of bloody show
Intermittent, painless contractions
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Discuss the client's food preferences with the hospital's dietitian: Collaborating with the dietitian allows the meal plan to be adjusted based on the client’s cultural, religious, or taste preferences while still meeting dietary requirements. This promotes adherence to the prescribed diet and supports patient-centered care.
B. Allow the client’s family to bring food from home for the client: While family support is valuable, food brought from home may not comply with the ADA diet. This can compromise glucose control unless the food is reviewed and approved by a dietitian.
C. Offer the client’s meals on a different schedule: Changing the meal schedule may not address the client’s refusal to eat if the issue is related to food content rather than timing. Consistency in meal timing is also important in managing blood glucose levels.
D. Request the provider change the client’s prescribed diet: Altering the diet order without first exploring and addressing the client’s preferences or challenges may lead to poor glucose control. The nurse should advocate for personalized modifications rather than a blanket diet change.
Correct Answer is C
Explanation
Rationale:
A. Increased salivation: Increased salivation is not an expected effect of cardiac catheterization. It may indicate a reaction to medication or anxiety but is not directly associated with the procedure.
B. Headache: While headaches can occur with some cardiac medications or contrast agents, they are not typical or expected during catheterization itself. Persistent headaches should be reported and evaluated further.
C. Sensation of skin warmth: A warm or flushed sensation is a common and expected finding during cardiac catheterization due to the injection of contrast dye. Patients are typically informed in advance to reduce alarm.
D. Numbness and tingling of the extremities: These sensations may suggest compromised circulation or nerve involvement, which is not expected and should be promptly reported. It could indicate a complication from arterial access.
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