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?
Contraction intensity increased by ambulation
Slow change in dilation and effacement
Presence of bloody show
Intermittent painless contractions
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Critical pathways should reduce health care costs. Critical pathways, also known as clinical pathways or care maps, are evidence-based, multidisciplinary plans that outline expected care and outcomes for specific conditions. They aim to improve care efficiency, reduce complications, and lower healthcare costs by standardizing care.
B. Nurses should discontinue the critical pathway if variances occur. Variances—deviations from the expected pathway—are documented and analyzed, not a reason to discontinue the pathway. They help identify areas for improvement or necessary adjustments in patient care.
C. Critical pathways have an unlimited timeframe for completion. Critical pathways are time-bound, with specific goals and milestones to be met within a set timeframe based on typical recovery patterns for the condition being treated.
D. Nurses' notes are used to create the critical pathway. Critical pathways are developed using evidence-based guidelines, expert consensus, and clinical research, not individual nurses’ progress notes. However, nurses do document progress and variances within the pathway.
Correct Answer is A
Explanation
A. Orange slices. Vitamin C-rich foods like oranges enhance the absorption of nonheme iron, which is found in plant-based sources such as legumes, leafy greens, and fortified cereals. This is especially important for vegetarians who rely on nonheme iron sources.
B. Boiled eggs. While eggs contain iron, they also contain phosphoproteins that can actually inhibit iron absorption. They do not enhance the absorption of nonheme iron and are not ideal for this purpose.
C. Mixed nuts. Nuts provide a source of nonheme iron but do not significantly enhance iron absorption. They lack vitamin C, which is essential for improving nonheme iron bioavailability.
D. Cheddar cheese. Dairy products like cheese contain calcium, which can inhibit iron absorption. They are not recommended to enhance iron uptake, particularly when consuming nonheme iron.
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