A nurse is attending to a client who is a first-time mother, at term, and experiencing contractions. She is uncertain if she is in labor.Which of the following would the nurse identify as an indication of true labor?
Pattern of contractions.
Rupture of the membranes.
Position of the presenting part.
Changes in the cervix.
The Correct Answer is A
Choice A rationale
This is the correct answer. Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor.
Choice B rationale
Rupture of the membranes can occur before or during labor, but it is not a definitive sign of true labor.
Choice C rationale
The position of the presenting part is not a definitive sign of true labor.
Choice D rationale
Changes in the cervix can be a sign of true labor, but without regular, strong contractions, it is not a definitive sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Uteroplacental insufficiency causes late decelerations due to reduced oxygenation, not mechanical pressure. It reflects placental dysfunction, not direct cranial compression effects.
Choice B rationale: Spontaneous rupture of membranes increases infection and labor risk but does not directly alter cerebral perfusion or trigger vagal responses linked to head compression.
Choice C rationale: Altered fetal cerebral blood flow results from cranial pressure during contractions, triggering vagal stimulation and early decelerations. This is the physiological response to head compression.
Choice D rationale: Umbilical cord compression causes variable decelerations due to transient blood flow obstruction, unrelated to cranial pressure or cerebral perfusion changes.
Correct Answer is D
Explanation
Choice A rationale
While changes in an infant’s sleep patterns can be a sign of many issues, they are not a specific indicator of a food allergy.
Choice B rationale
Rice cereals are typically one of the first foods introduced to infants and are usually well- tolerated. They are not known to cause problems during lactation.
Choice C rationale
The foods a mother eats can affect breast milk, but they do not typically cause food allergies. Most babies can tolerate a variety of foods in a mother’s diet without any problems.
Choice D rationale
If there is a strong family history of peanut allergies, the mother might want to avoid eating peanuts while breastfeeding. However, current research suggests that early exposure to potential allergens may actually decrease the risk of developing allergies.
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