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. Action: The action stage involves actively implementing strategies to change behavior. Since the group is already in the process of reducing pesticide use, they are taking concrete steps toward achieving their goal, which defines the action phase.
B. Maintenance: Maintenance occurs after a behavior has been successfully adopted and sustained over time. The group has not yet reached this phase, as they are still actively working on the change rather than maintaining it.
C. Contemplation: Contemplation is the stage where individuals or groups are considering a change but have not yet committed to or started the process. The group’s involvement in reducing pesticide use suggests they have moved beyond this phase.
D. Preparation: Preparation includes making plans and gathering resources to initiate change. While the group may have gone through this stage, the current activity of reducing pesticide use indicates they have progressed to the action stage.
Correct Answer is B
Explanation
Rationale:
A. Pupil diameter 6 mm: Dilated pupils may indicate CNS stimulation or sensitivity, but this finding is less immediately life-threatening than significant hypotension. Pupil size should still be monitored, especially for signs of overdose or neurologic changes.
B. Blood pressure 80/40 mm Hg: Severe hypotension is a critical adverse effect of IV morphine that can compromise perfusion to vital organs. It requires immediate attention to prevent shock, making this the highest priority finding to report.
C. Urinary output 120 mL/4 hr: While this output is slightly below normal, it does not yet indicate acute kidney injury. Continued monitoring is warranted, but it is not the most urgent issue compared to hypotension.
D. Bowel movement 5 days ago: Constipation is a common side effect of opioids, but it typically develops gradually and can be managed with bowel protocols. It is not as urgent as hypotension and can be addressed after stabilizing the client.
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