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A nurse is caring for a client in the labor and delivery unit.

Which of the following findings indicate that the client is in labor Select all that apply.

Urinalysis

Contraction intensity

Cervical dilation

Vaginal discharge

Nitrazine results

Maternal temperature

Contraction frequency

Fetal heart rate

Answer and Explanation

Correct Answer : B,E,G

A. Urinalysis: The urinalysis shows leukocyte esterase positivity, which suggests a possible urinary tract infection rather than an indication of labor. While infections can contribute to discomfort and complications, urinalysis findings do not confirm the onset of labor and therefore are not considered indicators of labor progress.

B. Contraction intensity: The client reports contractions that are becoming stronger over the last few hours, with pain rising to 8 out of 10 during contractions. Increasing contraction intensity is a typical sign that labor is progressing, as contractions become more forceful and effective in promoting cervical change.

C. Cervical dilation: The last cervical exam was performed five days ago and showed no dilation, and the current scenario provides no evidence of updated cervical assessment. Without current cervical findings, dilation cannot be used as an indicator of labor at this time, even though it is a defining feature when assessed directly.

D. Vaginal discharge: The client has been wearing a perineal pad for discharge for three days, but this chronic discharge does not necessarily represent labor onset. Vaginal discharge can increase during pregnancy for many benign reasons and requires nitrazine testing or other characteristics to confirm rupture of membranes.

E. Nitrazine results: The nitrazine test is positive, which suggests that the fluid may be amniotic rather than standard vaginal secretions. Rupture of membranes, whether spontaneous or premature, is an important sign associated with labor or imminent labor progression and requires follow-up assessment.

F. Maternal temperature: The temperature of 38.7°C (101.7°F) indicates a fever and raises concern for infection, such as chorioamnionitis or a urinary infection. A fever does not indicate labor directly; instead, it signals a need for medical evaluation to determine the cause and potential fetal implications.

G. Contraction frequency: Contractions occurring every five minutes for at least one hour suggest a rhythmic pattern typical of early labor. When contractions become regular and progressively closer together, this pattern is consistent with true labor rather than Braxton Hicks contractions.

H. Fetal heart rate: The fetal heart rate of 140 beats per minute is within normal limits for a term fetus and does not indicate labor progression. FHR trends help evaluate fetal well-being but do not provide specific information confirming the presence or advancement of labor.

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Correct Answer is A

Explanation

A. Educating the client how to cover nose and mouth with tissues when coughing: Covering the nose and mouth helps prevent airborne transmission of Mycobacterium tuberculosis. Proper disposal of tissues and hand hygiene further reduce the risk of spreading the infection to others.

B. Recommending the client may return to work after two negative sputum cultures: Returning to work should only be considered after the client is no longer contagious and cleared by the healthcare provider. This often requires multiple negative sputum cultures and clinical evaluation, not just a time-based recommendation.

C. Instructing the client that he is no longer contagious after 1 week of medication therapy: Clients with active TB are not automatically non-contagious after one week of therapy. Contagiousness decreases gradually, and adherence to medication and follow-up sputum tests determine when the client is safe to interact with others.

D. Teaching the client’s family to wear protective masks while with the client: Family members do not routinely need masks if proper airborne precautions are in place and the client is receiving treatment at home. Emphasis should be on client respiratory hygiene, ventilation, and adherence to treatment.

A. Compulsive attention to details B. Avoids interacting with others C. Uses others for personal gain D. Socially awkward in group situations

Correct Answer is C

Explanation

A. Compulsive attention to details: This behavior is more characteristic of obsessive-compulsive personality disorder, not antisocial personality disorder. It reflects a need for order and control rather than disregard for others.

B. Avoids interacting with others: Social withdrawal is typical of avoidant personality disorder. Clients with antisocial personality disorder generally seek interactions they can exploit, rather than avoiding social contact.

C. Uses others for personal gain: Exploiting others for personal benefit is a hallmark of antisocial personality disorder. Clients often display deceitfulness, manipulativeness, and a lack of regard for the rights or feelings of others, consistent with this diagnosis.

D. Socially awkward in group situations: Social awkwardness may be seen in schizoid or schizotypal personality disorders. Clients with antisocial personality disorder usually engage socially in a confident or charming manner when it serves their goals, rather than showing awkwardness.

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A nurse is caring for a client in the labor and delivery unit.

Which of the following findings indicate that the client is in labor Select all that apply.