A primigravida arrives at the maternity unit’s observation area because she believes she is in labor.
The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes.
Which assessment finding would confirm to the nurse that the client is not in labor at this time?

Cervical dilation is 1 cm.

Contractions decrease with walking.

There is 2+ pitting edema in the lower extremities.

The membranes are intact.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Cervical dilation is a sign of labor, but a dilation of 1 cm alone does not confirm active labor. It could be the early phase of labor or false labor.

Choice B rationale

Contractions that decrease with walking are typically associated with false labor. In true labor, contractions usually get stronger regardless of activity level.

Choice C rationale

While 2+ pitting edema in the lower extremities can be seen in pregnancy, it is not a reliable indicator of labor. It could be due to fluid retention or other conditions.

Choice D rationale

The status of the membranes (intact or ruptured) does not necessarily indicate whether a woman is in labor. Some women may experience membrane rupture before labor begins.

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Correct Answer is D

Explanation

Choice A rationale

While pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.

Choice B rationale

Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.

Choice C rationale

Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.

Choice D rationale

Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.

A. Inspect the client’s face for edema. B. Inquire about a history of cluster headaches. C. Determine the frequency of headaches. D. Monitor and time the client’s contractions.

Correct Answer is A

Explanation

Choice A rationale

A client at 32 weeks gestation reporting nausea, vomiting, and elevated blood pressure could be showing signs of a condition called gestational hypertension or preeclampsia. This condition can affect the health of both the mother and the baby, depending on how severe the issue is. Inspecting the client’s face for edema is a relevant next step because swelling in the face, hands, or fingers is a common symptom of preeclampsia.

Choice B rationale

While headaches can be a symptom of preeclampsia, asking about a history of cluster headaches may not be the most immediate concern in this situation. Cluster headaches are a specific type of headache that is not directly related to pregnancy or preeclampsia.

Choice C rationale

Determining the frequency of headaches could be useful in assessing the client’s overall health, but it may not be the most immediate concern when the client is showing potential signs of preeclampsia.

Choice D rationale

Monitoring and timing the client’s contractions would be more relevant if the client was in labor or showing signs of preterm labor. In this case, the client’s symptoms are more indicative of a hypertensive disorder of pregnancy.

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Naxlex Comprehensive Predictor Exams

What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

Correct Answer is D

Explanation

A client at 32 weeks gestation visits the women’s health clinic and reports feeling nauseous and vomiting. Upon examination, the nurse notes that the client’s blood pressure is elevated.What should the nurse do next?

Correct Answer is A

Explanation

A client at 35 weeks gestation complains of pain whenever the baby moves.The nurse notes the client’s temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation.What condition do these findings suggest?

Which signs of postpartum depression require additional attention from the nurse? (Select all that apply.)

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The nurse is caring for a client who delivered 6 hours ago.The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?