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 A
Explanation
Choice A rationale
Late decelerations in the Fetal Heart Rate (FHR) are a type of FHR pattern observed during labor, indicating a potential compromise of fetal well-being. They often begin just after a contraction, with their lowest point occurring after the peak of the contraction. These decelerations are associated with maternal and fetal conditions. Changing the client’s position can help alleviate the pressure on the fetus and improve blood flow, potentially reducing the occurrence of late decelerations. Therefore, the first action the nurse should take when noting late decelerations in the FHR is to change the client’s position.
Choice B rationale
Applying a fetal scalp electrode is a method used to monitor the FHR more accurately. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Choice C rationale
Administering oxygen can help increase the oxygen supply to the fetus. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Choice D rationale
Increasing the rate of the IV infusion can help improve uteroplacental perfusion. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Correct Answer is D
Explanation
-
G (Gravida): Total number of pregnancies → 4
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T (Term births): Delivered at 37 weeks or more → One (39 weeks) → T = 1
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P (Preterm births): Delivered between 20–36 weeks → Twins (34 weeks, 1 pregnancy) + One at 35 weeks = 2 preterm pregnancies → P = 2
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A (Abortions): Pregnancies ending before 20 weeks → 0
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L (Living children): One from term birth, two from twins, and one from the other preterm = 4 living children → L = 4
Correct Answer: D. G4 T1 P2 A0 L4
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