A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not.”. Which of the following should the nurse recognize as a sign of true labor?

Choice A reason:

Rupture of the membranes is not a reliable sign of true labor, as it can occur before or during labor, or be artificially induced by the provider. • Choice B reason:

Patterns of contractions can vary depending on the stage and phase of labor, and can also be influenced by factors such as hydration, activity, and medication. Contractions alone do not indicate true labor unless they are accompanied by cervical changes. • Choice C reason:

Changes in the cervix, such as effacement (thinning) and dilation (opening), are the most accurate indication of true labor. Cervical changes are caused by the pressure of the presenting part and the force of the contractions. The nurse should assess the cervix periodically to determine the progress of labor. • Choice D reason:

The station of the presenting part refers to the relationship of the fetal head to the maternal ischial spines, which are bony landmarks in the pelvis. The station can range from -5 (high) to +5 (low), with 0 being at the level of the ischial spines. Station does not indicate true labor, as it can vary depending on the parity, pelvic shape, and fetal position of the client.

Choice A reason:

The cord is still pulsating. This is not the first thing a nurse must ensure when the head comes out because the cord normally pulsates until the placenta is delivered. The pulsation indicates that the cord is still functioning and transferring blood and oxygen between the baby and the placenta. However, this does not mean that the cord is free from any complications that could endanger the baby's life, such as a nuchal cord (a cord wrapped around the neck) or a prolapsed cord (a cord that slips out before the baby). • Choice B reason:

The cord is intact. This is not the first thing a nurse must ensure when the head comes out because the cord is usually intact until it is clamped and cut after the delivery of the baby. The cord can be ruptured by excessive traction or twisting, which can cause bleeding and shock in the baby. However, this is a rare occurrence and does not pose an immediate threat to the baby's life as long as the cord is still attached to the placenta. • Choice C reason:

No part of the cord is encircling the baby's neck. This is the correct answer because a nuchal cord can cause compression of the cord and reduce blood flow and oxygen to the baby, leading to fetal distress, hypoxia, and brain damage. A nuchal cord occurs in about 10 to 30 percent of deliveries and can be detected by feeling for a loop of cord around the neck as the head emerges. If a nuchal cord is present, it should be gently slipped over the head or clamped and cut before delivery of the shoulders. • Choice D reason:

The cord is still attached to the placenta. This is not the first thing a nurse must ensure when the head comes out because the cord is always attached to the placenta until it separates from the uterine wall and is expelled after the delivery of the baby. The placenta provides nourishment and oxygen to the baby through the cord. However, this does not mean that the cord is free from any complications that could endanger the baby's life, such as a nuchal cord or a prolapsed cord.