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 A
Explanation
Choice A rationale
This is correct because the newborn might be actively shedding the virus if the mother has rubella at the time of delivery. Rubella is a highly contagious viral infection that can be transmitted through respiratory droplets or contact with body fluids. The newborn should be placed in isolation to prevent the spread of the infection to other susceptible individuals, such as pregnant women or immunocompromised persons.
Choice B rationale
This is incorrect because the child might develop encephalitis, a complication of rubella, is not an appropriate response by the nurse. Encephalitis is a rare but serious condition that involves inflammation of the brain. It can occur as a complication of rubella, but it is more common in adults than in children. The nurse should not scare the mother with this possibility, but rather focus on the prevention of transmission.
Choice C rationale
This is incorrect because the newborn is at risk for developing a TORCH infection is not an appropriate response by the nurse. TORCH is an acronym for a group of infections that can cause congenital anomalies in the fetus or newborn. It stands for toxoplasmosis, other infections (such as syphilis, varicella, or parvovirus), rubella, cytomegalovirus, and herpes simplex virus. The nurse should not use this term, as it is vague and confusing for the mother. The nurse should specify the type of infection and the potential consequences for the newborn.
Choice D rationale
This is incorrect because exposure to rubella will suppress the newborn's immune response is not an appropriate response by the nurse. Exposure to rubella will not suppress the newborn's immune response, but rather stimulate it to produce antibodies against the virus. However, these antibodies may not be sufficient to protect the newborn from the infection, and they may interfere with the effectiveness of the rubella vaccine later in life. The nurse should explain the importance of immunization for the newborn and the mother.
Correct Answer is A
Explanation
Choice A rationale
Risk for injury related to seizures is an important nursing diagnosis for this client. The client is at risk of seizures due to the severe preeclampsia and the high blood pressure. Seizures can cause injury to the client and the fetus, as well as complications such as aspiration, cerebral hemorrhage, and coma. The nurse should monitor the client's neurological status, administer anticonvulsants as prescribed, and protect the client from injury during a seizure.
Choice B rationale
Impaired gas exchange related to pulmonary edema is an important nursing diagnosis for this client. The client is at risk of pulmonary edema due to the fluid overload and the high blood pressure. Pulmonary edema can impair the gas exchange and oxygen delivery to the client and the fetus, as well as cause respiratory distress, heart failure, and death. The nurse should monitor the client's respiratory status, administer oxygen as prescribed, and restrict the fluid intake.
Choice C rationale
Deficient fluid volume related to diuresis is not an important nursing diagnosis for this client. The client is not at risk of deficient fluid volume, but rather fluid overload. Diuresis is the increased production and excretion of urine, which can cause fluid loss and dehydration. The client does not have any signs of diuresis, such as increased urine output, decreased specific gravity, or weight loss.
Choice D rationale
Ineffective tissue perfusion related to placental abruption is not an important nursing diagnosis for this client. The client is not at risk of placental abruption, but rather uteroplacental insufficiency. Placental abruption is the premature separation of the placenta from the uterine wall, which can cause bleeding, pain, and fetal distress. The client does not have any signs of placental abruption, such as vaginal bleeding, abdominal tenderness, or fetal heart rate abnormalities.
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