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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Assess the client's peripheral pulses every 15 min: Frequent assessment of peripheral pulses is essential to monitor for signs of arterial obstruction, bleeding, or hematoma formation at the femoral site. This helps ensure adequate perfusion and detect complications early.

B. Elevate the head of the client's bed to 45°: After femoral catheterization, the head of the bed should be elevated no more than 30° to reduce pressure at the puncture site and prevent bleeding. A 45° angle may increase the risk of hemorrhage.

C. Change the client's dressing 4 hr following the procedure: The dressing should remain in place and be monitored for signs of bleeding or saturation. Routine dressing changes shortly after the procedure are not recommended unless soiled or ordered.

D. Instruct the client to flex the right knee every 30 min: Flexing the leg increases the risk of dislodging the clot or reopening the arterial puncture site. The affected leg should remain straight and immobilized for several hours post-procedure.

A. Monitor the client's vital signs every hour following the procedure. B. Review the client's platelet count level prior to the procedure. C. Inform the client that their bladder should be full before the procedure. D. Obtain the client's consent following the procedure.

Correct Answer is B

Explanation

Rationale:

A. Monitor the client's vital signs every hour following the procedure: Vital signs, especially blood pressure, should be monitored more frequently—usually every 5 to 15 minutes immediately after epidural initiation—to assess for hypotension, a common complication.

B. Review the client's platelet count level prior to the procedure: A low platelet count increases the risk of epidural hematoma during needle insertion. Reviewing coagulation status is essential to ensure it's safe to proceed with epidural placement.

C. Inform the client that their bladder should be full before the procedure: The bladder should be emptied, not full, prior to the procedure. A full bladder increases discomfort, impairs fetal descent, and may lead to urinary retention after the epidural is placed.

D. Obtain the client's consent following the procedure: Informed consent must be obtained before any invasive procedure, including epidural anesthesia. Performing the procedure without prior consent violates patient autonomy and legal standards.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 is postoperative immediately following a cardiac catheterization with a right femoral approach. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting with the initiation of epidural analgesia for a client who is in the second stage of labor. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit is planning care for assigned clients. Which of the following actions should the nurse plan to take to demonstrate effective time management?

A nurse is caring for a client. Exhibits The nurse is assessing the client. Select the 4 findings that require immediate follow-up.

A nurse is caring for a client who is experiencing status epilepticus. Which of the following medications should the nurse expect to administer?

A nurse is caring for a client who has preeclampsia and is experiencing a postpartum hemorrhage. The nurse should expect the provider to prescribe which of the following medications?

A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A nurse in an emergency department is planning care for a client who has abdominal trauma from a motor-vehicle crash. Which of the following provider prescriptions should the nurse implement first?

A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?