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 A

Explanation

The correct answer is A. Shoulder dystocia. Retraction of the fetal head against the maternal perineum as the head is birthed is a classic sign of shoulder dystocia. This is a birth complication where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery.

A. A client who has missed a menstrual cycle and reports vaginal spotting. B. A client who is at 28 weeks of gestation and reports painless vaginal bleeding. C. A client who is at 38 weeks of gestation and reports symptoms of a cough and fever. D. A client who is at 14 weeks of gestation and reports experiencing nausea and vomiting.

Correct Answer is B

Explanation

Choice A rationale
Missing a menstrual cycle and reporting vaginal spotting could indicate early pregnancy or other non-emergency conditions. While this client should be evaluated, it is not the highest priority.
Choice B rationale
A client at 28 weeks of gestation reporting painless vaginal bleeding could be experiencing placenta previa or placental abruption, both of which are obstetric emergencies. This client should be prioritized for immediate evaluation.
Choice C rationale
A client at 38 weeks of gestation reporting symptoms of a cough and fever may have an upper respiratory infection. While this should be evaluated, it is not the highest priority unless the client is in distress.
Choice D rationale
Nausea and vomiting are common in early pregnancy. A client at 14 weeks of gestation reporting these symptoms would need evaluation, but it is not the highest priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Which condition is the client most likely experiencing?

Correct Answer is A

Explanation

As a nurse in an antepartum unit performing triage, which client should be prioritized?

Correct Answer is B

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?