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 ["C","E","H","I"]
Explanation
Findings that require follow-up:
Uterus boggy at 24 hr postpartum:
A boggy uterus indicates poor uterine contraction, which can lead to postpartum hemorrhage. Effective uterine contraction is crucial to prevent excessive bleeding after delivery, and this finding warrants immediate intervention, such as fundal massage or administering uterotonic medications.
Lochia rubra with foul odor:
Foul-smelling lochia is a sign of potential infection, often indicative of endometritis, which is an infection of the uterine lining. The presence of this odor requires prompt follow-up and possibly antibiotic treatment to prevent further complications.
Elevated temperature (38.3°C/100.9°F) at 24 hr postpartum:
A postpartum fever may indicate infection, such as endometritis or a urinary tract infection (UTI). This fever should be investigated further to determine the cause and appropriate treatment, as untreated infections can lead to serious complications.
Increased heart rate (105/min) at 24 hr postpartum:
Tachycardia in the postpartum period can be a sign of infection or early signs of hemodynamic instability, possibly due to blood loss or infection. Close monitoring is necessary, and the healthcare provider should be notified to evaluate the cause and initiate treatment if necessary.
Correct Answer is B
Explanation
A) Flexion:
Flexion is a movement where the fetal head bends forward during labor, which allows the smallest diameter of the head to pass through the birth canal. It is an important part of the labor process but does not refer to the initial descent of the fetus into the pelvis. Flexion typically occurs once the fetus begins to descend into the pelvis.
B) Engagement:
Engagement refers to the initial descent of the fetal head into the pelvis and the passage of the largest part of the fetal head (the biparietal diameter) into the maternal pelvis. This occurs when the fetal head reaches zero station at the level of the ischial spines and is the first cardinal movement of labor. It marks the point at which the presenting part of the fetus enters the pelvic inlet and begins the process of descent.
C) Extension:
Extension is the movement of the fetal head as it exits the birth canal after engagement and descent. The head moves from a flexed position (chin to chest) to an extended position (chin moving away from the chest) as it passes through the birth canal. This movement occurs after engagement and is a part of the expulsion phase, not the initial descent.
D) Expulsion:
Expulsion is the final phase of labor, which occurs after the fetal head has been delivered. It involves the delivery of the rest of the body (shoulders, torso, and legs) following the birth of the head. This is the final cardinal movement, which takes place after engagement, descent, flexion, internal rotation, extension, and external rotation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.