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
This is the best response because it acknowledges the client’s question and refers her to a healthcare provider who can provide a comprehensive assessment and discuss the most appropriate contraceptive options for her specific situation.
Choice B rationale
While it’s important to understand a client’s sexual activity when discussing contraception, asking a minor about her sexual activity without a proper context or professional setting may be inappropriate and uncomfortable for the client.
Choice C rationale
This response may come off as judgmental or condescending. It’s crucial to provide a safe and non-judgmental environment when discussing sensitive topics like sexual health and contraception.
Choice D rationale
While barrier methods can be an effective form of contraception, it’s not appropriate to recommend a specific method without a thorough understanding of the client’s health history, lifestyle, and preferences.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Variable decelerations are not related to fetal head compression. Fetal head compression typically results in early decelerations, not variable ones.
Choice B rationale
Variable decelerations are indeed due to umbilical cord compression. They are quick decreases in fetal heart rate that vary with uterine contractions. This can be a sign that the baby’s blood flow is reduced if variable decelerations happen over and over.
Choice C rationale
Uteroplacental insufficiency typically results in late decelerations, not variable ones. Late decelerations are a sign of fetal hypoxia and are associated with uteroplacental insufficiency.
Choice D rationale
While certain medications can affect the fetal heart rate, variable decelerations are not typically a result of the administration of narcotic analgesics.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.