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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
The term “effaced” refers to the thinning of the cervix, which is a process that occurs as labor approaches. However, the documentation “-1” does not indicate the degree of cervical effacement.
Choice B rationale
The term “presenting part is 1 cm below the ischial spines” would be documented as “+1” in a vaginal examination. This indicates that the presenting part of the fetus (usually the head) is 1 cm below the ischial spines, which are bony landmarks in the maternal pelvis.
Choice C rationale
The documentation “-1” in a vaginal examination refers to the position of the presenting part of the fetus in relation to the ischial spines of the maternal pelvis. A “-1” indicates that the presenting part is 1 cm above the ischial spines. This is a common finding during labor and does not indicate any abnormality.
Choice D rationale
The term “dilated” refers to the opening of the cervix. In the context of labor and delivery, the cervix dilates from 0 to 10 cm to allow for the passage of the baby. However, the documentation “-1” does not provide information about the degree of cervical dilation.

A. 0.5 mL B. 1 mL C. 1.5 mL D. 2 mL .

Correct Answer is A

Explanation

Step 1 is to calculate the volume of Toradol to be drawn up. Toradol is available in 60 mg/mL. Therefore, to administer a dose of 30 mg, the nurse would need to draw up 30 mg ÷ 60 mg/mL = 0.5 mL.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse on the labor and delivery unit is caring for a patient following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?

Correct Answer is C

Explanation

Three hours post cesarean section, the physician orders Toradol 30 mg IM every 6 hours for pain. Toradol is available in 60 mg/mL. How many mLs should be drawn up?

Correct Answer is A

Explanation

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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?