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

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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Correct Answer is A

Explanation

Rationale:

A. Ask the client if they would prefer a translator who is the same gender: Offering a professional interpreter of the same gender, when possible, shows cultural sensitivity and promotes client comfort and openness, especially for intimate or personal health discussions.

B. Use a website with a ".com" URL to translate for the client: Websites, especially commercial ones, may be inaccurate or unreliable for medical translation. Miscommunication through these tools can result in errors and compromise client safety.

C. Request a family member of the client to translate: Family members may unintentionally alter or filter information, leading to errors or withholding of critical health data. It also poses confidentiality concerns and is not considered a best practice.

D. Ask a nursing student who speaks the same language as the client to translate: Unless the student is a certified medical interpreter, this action is inappropriate. Medical interpretation requires training to ensure accurate, unbiased communication that upholds privacy and safety.

A. Insert the oral thermometer in front of the Infant's tongue. B. Pull the pinna of the infant's ear forward before inserting the probe C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum D. Place the tip of the thermometer under the center of the infant's axilla.

Correct Answer is D

Explanation

Rationale:

A. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is not appropriate for infants due to the risk of injury and their inability to hold the thermometer properly. It is generally reserved for children older than 4–5 years.

B. Pull the pinna of the infant's ear forward before inserting the probe: When using a tympanic thermometer for infants under 3 years, the correct method is to pull the pinna down and back, not forward, to straighten the ear canal.

C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: This depth is too invasive and risks rectal perforation. For infants, rectal insertion should be only 1.5 to 2.5 cm (0.6–1 in), with extreme caution.

D. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature is the safest and most noninvasive route for infants. Ensuring full skin contact under the center of the axilla provides the most accurate axillary reading.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take when communicating with the client?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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