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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Administering oxygen via face mask is a secondary intervention for late decelerations, which indicate fetal hypoxia. Oxygen may improve the fetal oxygenation, but it does not address the underlying cause of the late decelerations, which is uteroplacental insufficiency.
Choice B rationale
Increasing the infusion rate of the IV fluid is another secondary intervention for late decelerations. IV fluid may increase the maternal blood volume and cardiac output, but it does not improve the placental blood flow, which is the main problem in late decelerations.
Choice C rationale
Elevating the client's legs is not an appropriate intervention for late decelerations. Elevating the legs may reduce the venous return and lower the blood pressure, which can worsen the uteroplacental insufficiency and the fetal hypoxia.
Choice D rationale
Positioning the client on her side is the priority nursing action for late decelerations. This position reduces the pressure of the gravid uterus on the inferior vena cava and the aorta, which improves the maternal and fetal circulation and oxygenation.
Correct Answer is B
Explanation
Choice A rationale
This is incorrect because variable decelerations are not related to fetal head compression. Fetal head compression causes early decelerations, which are symmetrical and mirror the shape of the uterine contraction.
Choice B rationale
This is correct because variable decelerations are due to umbilical cord compression. Umbilical cord compression reduces the blood flow and oxygen delivery to the fetus, resulting in abrupt and irregular decreases in the fetal heart rate that vary in onset, depth, and duration.
Choice C rationale
This is incorrect because variable decelerations are not caused by uteroplacental insufficiency. Uteroplacental insufficiency causes late decelerations, which are symmetrical and begin after the peak of the uterine contraction.
Choice D rationale
This is incorrect because variable decelerations are not a result of the administration of narcotic analgesics. Narcotic analgesics can cause a decrease in the baseline fetal heart rate and variability, but not variable decelerations.
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