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A nurse is teaching a client who is at 27 weeks of gestation and has pre-term labor about the signs and symptoms of true labor versus false labor.

Which of the following information should the nurse include in the teaching?

True labor contractions are irregular and subside with rest

False labor contractions are felt in the lower back and radiate to the abdomen

True labor contractions cause cervical dilation and effacement

False labor contractions increase in intensity with ambulation

Answer and Explanation

The Correct Answer is C

True labor contractions cause cervical dilation and effacement.

This means that the cervix opens up and thins out to prepare for the baby’s passage through the birth canal.

Cervical changes can be measured by a pelvic exam.

Choice A is wrong because true labor contractions are regular and do not subside with rest. False labor contractions are irregular and may stop when you change position or activity level.

Choice B is wrong because false labor contractions are usually felt in the front of the abdomen, not in the lower back. True labor contractions may start in the back and radiate to the abdomen.

Choice D is wrong because false labor contractions do not increase in intensity with ambulation. True labor contractions may become stronger and closer together when you walk.

Normal ranges for cervical dilation and effacement vary depending on the stage of labor, but generally, full dilation is 10 cm and full effacement is 100%.

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Correct Answer is A

Explanation

Assess fetal heart rate and activity.

The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk forpremature rupture of membranes (PROM), which can lead toinfection,cord prolapse, andfetal distress.Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.

Choice B is wrong because performing a nitrazine test on the fluid is not the first action.A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.

Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation.Oxytocin is used to induce or augment labor, but it can causeuterine hyperstimulation,fetal distress, andplacental abruptionif given to a client who has PROM.

Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM.Trendelenburg position can increase the risk ofcord prolapseandaspirationin this situation.

A. Administer a dose of tocolytic medication B. Encourage the client to rest in a side-lying position C. Assess fetal heart rate using a Doppler device D. Assess vaginal discharge for any change

Correct Answer is C

Explanation

Assess fetal heart rate using a Doppler device.

This is because low back pain and pelvic pressure at 36 weeks of gestation may indicate preterm labor, which can affect the fetal well-being.Therefore, the nurse should assess the fetal heart rate as a priority to determine if the fetus is in distress or not.

Choice A is wrong because tocolytic medication is used to stop uterine contractions, not to relieve low back pain and pelvic pressure.Choice B is wrong because resting in a side-lying position may help with blood circulation and reduce supine hypotensive syndrome, but it does not address the possible cause of low back pain and pelvic pressure.Choice D is wrong because assessing vaginal discharge for any change may indicate infection, rupture of membranes, or cervical dilation, but it is not as urgent as assessing fetal heart rate.

Some interventions for preventing and treating low back pain and pelvic pressure during pregnancy include exercise, water-based exercise, acupuncture, osteomanipulative therapy, craniosacral therapy, and pelvic support belts.

However, these interventions should be discussed with the health care provider before starting them.

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A nurse is teaching a client who is at 27 weeks of gestation and has pre-term labor about the signs and symptoms of true labor versus false labor. Which of the following information should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 33 weeks of gestation and has pre-term labor. The client reports a sudden gush of fluid from her vagina. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a pregnant client at 36 weeks of gestation who reports low back pain and pelvic pressure. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

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A nurse is caring for a client who is receiving magnesium sulfate for pre-term labor. Which of the following assessments should the nurse perform to evaluate the therapeutic effect of the medication?

A nurse is planning discharge teaching for a client who is at 25 weeks of gestation and has pre-term labor that was successfully stopped with tocolytic therapy. Which of the following instructions should the nurse include in the teaching?

A nurse is teaching a client who is at risk for pre-term labor about the signs and symptoms to report to the provider. Which of the following should the nurse include in the teaching?

A nurse is teaching a client who is at 27 weeks of gestation and has pre-term labor about the signs and symptoms of true labor versus false labor.

Which of the following information should the nurse include in the teaching?