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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.

Contraction intensity increased by ambulation

B.

Slow change in dilation and effacement

C.

Presence of bloody show

D.

Intermittent painless contractions

Answer and Explanation

The Correct Answer is D

A. Contraction intensity increased by ambulation. This finding is typical of true labor, as walking or changing positions usually causes contractions to increase in strength, duration, and frequency. In contrast, false labor contractions often subside with rest or activity changes and do not intensify with movement.
B. Slow change in dilation and effacement. Any change in cervical dilation or effacement, even if slow, is more consistent with true labor. False labor does not produce any significant cervical change, and the cervix remains closed or minimally altered with time or contractions.
C. Presence of bloody show. Bloody show is the expulsion of the mucus plug mixed with blood, a common sign of cervical softening and dilation. This is a key indicator of true labor, as it reflects actual physical changes in preparation for delivery.
D. Intermittent painless contractions. These contractions, also called Braxton Hicks contractions, are a hallmark of false labor. They are usually irregular, mild, and do not lead to cervical changes. They often resolve with hydration, rest, or position changes and are considered a normal part of the body's preparation for labor, not the onset of true labor.
 


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Related Questions

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

Explanation

  • Lack of sleep: Decreased need for sleep is a core feature of mania, where individuals may go days with minimal rest and still appear energetic or overly active. It is not a defining feature of psychosis, though it may occur secondarily.
  • Pressured speech: Pressured, rapid, and difficult-to-interrupt speech is strongly associated with mania, reflecting accelerated thought processes and elevated mood. It is uncommon in psychosis unless mania and psychotic features coexist.
  • Disorganized thought process: This is a hallmark of psychosis, often seen in disorders like schizophrenia. It includes loose associations, tangentiality, and difficulty organizing ideas, and can impair communication significantly.
  • Excessive spending habits: Engaging in impulsive or risky financial behaviors is a classic symptom of mania, often driven by grandiosity or impaired judgment. This behavior is not typical of psychosis unless mania is also present.
  • Hallucinations: Perceptual disturbances such as seeing or hearing things that are not present are definitive features of psychosis. While they can occur in severe mania with psychotic features, they are primarily linked to psychotic disorders.

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

Explanation

  • Provide the client with high-calorie fluids every hr: Clients in manic states often experience poor nutritional intake due to hyperactivity and distractibility. Frequent, easy-to-consume high-calorie fluids help support caloric and hydration needs without requiring the client to sit for meals, making this an appropriate intervention.
  • Minimize environmental stimuli for the client: Clients experiencing mania are often overstimulated and agitated due to their heightened sensitivity and rapid thought processes. A low-stimulation environment helps reduce agitation, prevent escalation, and promote safety.
  • Weigh the client each day: While weight monitoring may be important in some psychiatric or medical conditions, daily weights are not a priority in the acute management of mania, particularly when the client is hyperactive, distracted, and unable to participate reliably. This could also increase agitation or preoccupation in some clients.
  • Encourage the client to avoid napping during the day: Manic clients often suffer from significantly reduced sleep, which contributes to worsening symptoms. Encouraging rest and short naps would be more therapeutic than promoting wakefulness, so avoiding naps is contraindicated in this scenario.

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