A nurse midwife is examining a client who is primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?
Amniotic fluid in the vaginal vault
Cervical dilation
Brownish vaginal discharge
Report of pain above the umbilicus
The Correct Answer is B
Choice A rationale
Amniotic fluid in the vaginal vault is not a definitive sign of labor. It indicates that the membranes have ruptured, which can occur before or during labor. However, some clients may not have their membranes ruptured until the late stages of labor or during delivery.
Choice B rationale
Cervical dilation is a definitive sign of labor. It indicates that the cervix is opening and thinning to allow the passage of the fetus. Cervical dilation is measured in centimeters from 0 to 10, with 10 being fully dilated and ready for delivery.
Choice C rationale
Brownish vaginal discharge is not a definitive sign of labor. It may indicate the presence of the bloody show, which is the mucus plug that seals the cervix during pregnancy. The bloody show may be expelled before or during labor, but it does not necessarily mean that labor has started.
Choice D rationale
Report of pain above the umbilicus is not a definitive sign of labor. It may indicate the presence of Braxton Hicks contractions, which are irregular and painless contractions that occur throughout pregnancy. They are also known as false labor contractions, as they do not cause cervical dilation or effacement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
This is incorrect because a client who has missed a period and reports vaginal spotting is not the most urgent case. This could indicate a possible pregnancy or a menstrual irregularity, but it is not a life-threatening condition. The nurse should see this client after assessing the other clients.
Choice B rationale
This is correct because a client who is at 28 weeks of gestation and reports painless vaginal bleeding is the most urgent case. This could indicate a placenta previa, which is a condition where the placenta covers the cervical opening and can cause severe hemorrhage and fetal distress. The nurse should see this client immediately and prepare for an emergency cesarean section.
Choice C rationale
This is incorrect because a client who is at 38 weeks of gestation and reports a cough and fever is not the most urgent case. This could indicate a respiratory infection, which can affect the maternal and fetal well-being, but it is not a life-threatening condition. The nurse should see this client after assessing the other clients and administer antibiotics and antipyretics as prescribed.
Choice D rationale
This is incorrect because a client who is at 14 weeks of gestation and reports nausea and vomiting is not the most urgent case. This could indicate a normal pregnancy symptom or a hyperemesis gravidarum, which is a condition where the nausea and vomiting are severe and persistent. The nurse should see this client after assessing the other clients and provide hydration and antiemetics as prescribed.
Correct Answer is B
Explanation
Choice A rationale
Gestational hypertension is not the most likely diagnosis for the client. Gestational hypertension is a condition where the blood pressure is elevated after 20 weeks of gestation, without any signs of proteinuria or end-organ damage. The client has a history of chronic hypertension for 5 years, which means that the hypertension existed before the pregnancy. The client also has proteinuria, which is a sign of preeclampsia.
Choice B rationale
Chronic hypertension with superimposed preeclampsia is the most likely diagnosis for the client. Chronic hypertension with superimposed preeclampsia is a condition where the blood pressure is elevated before 20 weeks of gestation, and the hypertension worsens or the proteinuria develops or increases after 20 weeks of gestation. The client has a history of chronic hypertension for 5 years, and the blood pressure is very high at 34 weeks of gestation. The client also has 3+ proteinuria, which indicates severe preeclampsia.
Choice C rationale
Eclampsia is not the most likely diagnosis for the client. Eclampsia is a condition where the preeclampsia progresses to cause seizures or coma in the pregnant woman. The client has no signs of seizures or coma, but only signs of preeclampsia.
Choice D rationale
HELLP syndrome is not the most likely diagnosis for the client. HELLP syndrome is a condition where the preeclampsia causes hemolysis, elevated liver enzymes, and low platelets in the pregnant woman. The client has no signs of hemolysis, liver damage, or thrombocytopenia, but only signs of preeclampsia.
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