A nurse is attending to a first-time pregnant woman who is at term.
She is experiencing contractions but is unsure if she is in labor.
Which of the following should the nurse identify as a labor sign?
The position of the presenting part.
Membrane rupture.
Contraction pattern.
Changes in the cervix.
The Correct Answer is D
Choice D rationale
Changes in the cervix, including effacement (thinning) and dilation (opening), are reliable signs of true labor. During true labor, contractions cause the cervix to thin and open to prepare for the passage of the baby. This is in contrast to Braxton Hicks contractions, or “false labor,” which are irregular and do not result in changes to the cervix.
Choice A rationale
The position of the presenting part can provide information about the progress of labor and the likely need for interventions, but it is not a definitive sign of labor.
Choice B rationale
Membrane rupture, or “water breaking,” can occur before or during labor. However, not all women experience a noticeable rupture of membranes, and sometimes the fluid can leak slowly, making it less noticeable.
Choice C rationale
A regular contraction pattern can be a sign of labor, but contractions can also occur in patterns during false labor. Therefore, contraction pattern alone is not a definitive sign of labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Vaginal discharge is common during pregnancy due to the increased production of estrogen and greater blood flow to the pelvic area. It is not typically a sign of preeclampsia.
Choice B rationale
Elevated blood pressure is a primary symptom of preeclampsia. If a pregnant client has high blood pressure, it should indicate to the nurse that the client requires further evaluation for this disorder.
Choice C rationale
Joint pain is not typically a symptom of preeclampsia. It could be related to other conditions or simply a result of the physical changes of pregnancy.
Choice D rationale
Increased urine output is not typically associated with preeclampsia. In fact, decreased urine output could potentially be a sign of kidney problems related to preeclampsia.
Correct Answer is A
Explanation
Choice A rationale
The correct transcription of two tenths of a milligram is 0.2 mg. This format avoids any potential confusion that could lead to a medication error.
Choice B rationale
While 0.20 mg is technically correct, it is not the preferred format. The trailing zero after the decimal point is unnecessary and could potentially lead to confusion.
Choice C rationale
20 mg is not correct. This is 100 times the intended dose of two tenths of a milligram, and could lead to a serious medication error.
Choice D rationale
2 mg is not correct. This is 10 times the intended dose of two tenths of a milligram, and could lead to a medication error.
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