A nurse Is caring for a primigravid client who is at 36 weeks of gestation and asks, "How will I know if I am in labor?" Which of the following manifestations of true labor should the nurse discuss with the client? (Select All that Apply.)
Contractions that increase in intensity
Leakage of fluid from the vagina
increased bladder pressure
Blood-tinged vaginal mucus
Uterine contractions that decrease with rest
Correct Answer : A,B,D
A) Contractions that increase in intensity:
This is a hallmark sign of true labor. In true labor, contractions become progressively more intense, frequent, and regular. They also do not subside with rest or changes in activity. The intensity of contractions gradually increases as the cervix dilates and effaces, signaling the onset of labor.
B) Leakage of fluid from the vagina:
Leakage of fluid from the vagina, particularly if it is clear and odorless, is indicative of rupture of membranes, which can occur in true labor. If the membranes rupture and there is a continuous leakage of fluid, it is important for the client to contact the healthcare provider as it may signal the onset of labor. This is a significant sign of labor, especially if accompanied by contractions.
C) Increased bladder pressure:
Increased bladder pressure can occur in pregnancy, especially as the uterus grows and presses on the bladder. However, bladder pressure alone is not a definitive sign of true labor. It can also be a common complaint during late pregnancy, even before labor begins. This symptom would not be specific to true labor.
D) Blood-tinged vaginal mucus:
A bloody show, or blood-tinged mucus, is another classic sign of true labor. This happens as the cervix begins to soften, dilate, and efface, causing small blood vessels in the cervix to break. The bloody show is typically a pink or brownish mucus discharge and can occur just before labor starts, signaling that the cervix is changing in preparation for delivery.
E) Uterine contractions that decrease with rest:
This is a characteristic of false labor (Braxton Hicks contractions). In false labor, contractions tend to decrease or stop when the woman changes position, rests, or hydrates. On the other hand, in true labor, contractions persist and increase in intensity and frequency even with rest or hydration. Therefore, this is not a sign of true labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Palmer grasp reflex:
The palmer grasp reflex is a primitive reflex in which a newborn will grasp an object placed in their hand. While this reflex is present at birth, it typically disappears by 5-6 months of age, not by 3-4 months. The Moro reflex, which is more related to startle and sudden movements, is the correct answer in this case.
B) Babinski reflex:
The Babinski reflex, in which the toes fan out when the sole of the foot is stroked, is present at birth but typically disappears by 12 months. This reflex is an indicator of neurological development, and its presence beyond the first year could suggest neurological concerns, but it is not the reflex in question here.
C) Rooting reflex:
The rooting reflex occurs when the newborn turns their head and opens their mouth in response to cheek stimulation, typically to find the nipple for breastfeeding. This reflex is present at birth and usually disappears by 3-4 months, which is similar to the timing mentioned in the question.
D) Moro reflex:
The Moro reflex is a startle reflex in which the infant spreads their arms and then pulls them back in when they feel a sudden loss of support or a loud noise. This reflex is present at birth and typically disappears by 3-4 months of age. It is considered a classic primitive reflex that fades as the infant's nervous system matures.
Correct Answer is B
Explanation
A) Category I:
Category I fetal heart rate patterns are considered normal and are characterized by a baseline fetal heart rate of 110–160 beats per minute, moderate variability, and the presence of accelerations. The pattern also lacks concerning decelerations. While this client’s fetal heart rate is within the normal baseline range (150 bpm), the presence of occasional variable decelerations indicates that the fetal heart rate pattern does not meet the criteria for Category I.
B) Category II:
Category II includes all fetal heart rate patterns that are not classified as Category I or III. This category represents indeterminate or concerning patterns, which require ongoing assessment and interventions. In this case, the fetal heart rate pattern includes a baseline within the normal range, moderate variability, accelerations, but also occasional variable decelerations. Variable decelerations, particularly when they occur intermittently, are often considered non-reassuring but not immediately concerning if they resolve quickly, placing the pattern in Category II.
C) Uncategorized:
"Uncategorized" refers to situations where the fetal heart rate pattern cannot be classified due to insufficient information or an unclear pattern. This is not applicable here because the nurse has identified sufficient data to classify the pattern.
D) Category III:
Category III patterns are considered abnormal and require prompt intervention. These patterns are characterized by persistent decelerations, such as late decelerations, bradycardia, or variable decelerations that do not resolve with interventions. Since the variable decelerations in this case are occasional and not persistent or severe, this pattern does not meet the criteria for Category III.
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