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?

Choice A rationale
Given the client’s symptoms and the fact that she is 34 weeks pregnant, the client is most likely experiencing preeclampsia. One of the severe complications of preeclampsia is eclampsia, which is characterized by the onset of seizures. Therefore, implementing seizure precautions would be an appropriate action for the nurse to take. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly.
Choice B rationale
Checking deep tendon reflexes every hour could be part of the care plan for a client with preeclampsia. Hyperreflexia can be a sign of worsening preeclampsia and impending seizure activity.
Choice C rationale
Methyldopa is a medication that can be used to control blood pressure in pregnant women. However, the question does not provide information that the client has been prescribed this medication.
Choice D rationale
Monitoring neurologic status is important in a client with preeclampsia due to the risk of eclampsia, which can cause seizures and other neurologic complications. However, implementing seizure precautions is a more immediate action to address the client’s condition.

Choice A rationale
Abdominal pain accompanied by minimal red vaginal bleeding is not a typical symptom of placenta previa. In placenta previa, the placenta covers all or part of the cervix, which can cause severe bleeding. However, this bleeding is typically not associated with abdominal pain.
Choice B rationale
Intermittent abdominal pain following the passage of bloody mucus is not a common symptom of placenta previa. This symptom is more commonly associated with labor or other conditions, but not specifically with placenta previa.
Choice C rationale
Increasing abdominal pain with a nonrelaxed uterus is not a typical symptom of placenta previa. This could be a sign of other complications such as uterine rupture or placental abruption, which are serious conditions that require immediate medical attention.
Choice D rationale
Painless red vaginal bleeding is indeed a symptom of placenta previa. This bleeding is usually bright red and can occur intermittently or continuously. It is most common in the third trimester of pregnancy.