A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor?
Select one:
"If I try to talk to my partner during a contraction, I can't."
"My contractions slow down when I walk around."
"I feel contractions start mostly in my back and they sweep around to the top of my abdomen."
"My contractions are about 6 minutes apart and regular."
The Correct Answer is B
Choice A Reason: "If I try to talk to my partner during a contraction, I can't." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor is a condition where there are regular and painful uterine contractions that cause cervical dilation and effacement, and lead to delivery of the baby and placenta. True labor contractions are usually strong and consistent, and they tend to increase or persist with activity or position changes. True labor contractions can be so intense that they interfere with speech or breathing.
Choice B Reason: ) "My contractions slow down when I walk around." This is because this statement by the client would lead the nurse to suspect that the woman is experiencing false labor, which is also known as Braxton Hicks contractions or practice contractions. False labor is a condition where there are irregular and painless uterine contractions that do not cause cervical dilation or effacement. False labor can occur throughout pregnancy, but it becomes more noticeable and frequent in late pregnancy. False labor contractions are usually weak and inconsistent, and they tend to decrease or stop with activity or position changes.
Choice C Reason: "I feel contractions start mostly in my back and they sweep around to the top of my abdomen." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor contractions usually start in the lower back and radiate to the lower abdomen or groin, following a wave-like patern. False labor contractions are more likely to be felt in the upper abdomen or sides, without a clear patern.
Choice D Reason: "My contractions are about 6 minutes apart and regular." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor contractions usually have a regular frequency and duration, and they become closer and longer as labor progresses. False labor contractions are more likely to have an irregular frequency and duration, and they do not change significantly over time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Rule out a suspected hydatidiform mole. This is an incorrect answer that describes an unlikely condition for this client. A hydatidiform mole is a type of gestational trophoblastic disease where abnormal placental tissue develops instead of a normal fetus. A hydatidiform mole can cause vaginal bleeding, hyperemesis gravidarum (severe nausea and vomiting), preeclampsia, and hyperthyroidism. A hydatidiform mole usually causes a fundal height measurement that is larger than expected for gestational age, not smaller.
Choice B Reason: Assess for congenital anomalies. This is an incorrect answer that implies that the client has not had a previous ultrasound to screen for fetal anomalies. Congenital anomalies are structural or functional defects that are present at birth, such as cleft lip, spina bifida, or Down syndrome. Ultrasound can detect some congenital anomalies by visualizing the fetal anatomy and morphology. However, ultrasound screening for fetal anomalies is usually done between 18 and 22 weeks of gestation, not at 32 weeks.
Choice C Reason: Determine fetal presentation. This is an incorrect answer that suggests that the client has an uncertain fetal presentation. Fetal presentation is the part of the fetus that is closest to the cervix, such as vertex (head), breech (butocks or feet), or transverse (shoulder). Fetal presentation can affect the mode and outcome of delivery. Ultrasound can determine fetal presentation by locating the fetal head and spine. However, fetal presentation can also be assessed by abdominal palpation or vaginal examination, which are simpler and less invasive methods.
Choice D Reason: Monitor fetal growth. This is because fundal height measurement is a method of estimating fetal size and gestational age by measuring the distance from the pubic symphysis to the top of the uterus (fundus) in centimeters. A fundal height measurement that is significantly smaller or larger than expected for gestational age may indicate intrauterine growth restriction (IUGR) or macrosomia, respectively. IUGR means that the fetal growth is slower than expected for gestational age, which can increase the risk of fetal distress, hypoxia, acidosis, and stillbirth. Macrosomia means that the fetal weight is higher than expected for gestational age, which can increase the risk of birth injuries, shoulder dystocia, cesarean delivery, and hypoglycemia. Ultrasound is a more accurate way of assessing fetal size and growth by measuring various parameters such as biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL). Ultrasound can also detect other factors that may affect fetal growth such as placental function, amniotic fluid volume, umbilical cord blood flow, and fetal anomalies.
Correct Answer is D
Explanation
Choice A Reason: "My baby will always be smaller than other babies his age." This is an incorrect answer that indicates a misconception or pessimism about SGA newborns. SGA newborns may not always be smaller than other babies their age, as they may catch up in growth and development with appropriate nutrition and care. SGA newborns may have different growth paterns depending on the cause and timing of their growth restriction.
Choice B Reason: "My baby will be okay as long as he has frequent feedings." This is an incorrect answer that indicates an oversimplification or optimism about SGA newborns. SGA newborns may not be okay with just frequent feedings, as they may have other problems or complications that require medical atention and intervention. SGA newborns may have increased nutritional needs and feeding difficulties due to low birth weight, poor suck-swallow coordination, or oral aversion.
Choice C Reason: "My baby will need to stay in the hospital until he weighs 5 pounds." This is an incorrect answer that indicates a misunderstanding or confusion about SGA newborns. SGA newborns may not need to stay in the hospital until they weigh 5 pounds, as they may be discharged earlier or later depending on their condition and readiness for home care. SGA newborns may have different criteria for discharge based on their gestational age, weight gain, feeding tolerance, temperature stability, and absence of complications.
Choice D Reason: "My baby can get cold easily, may have low blood sugar, and may have trouble breathing." This is because this statement by the parents indicates that they understand some of the common problems and complications that SGA newborns may face. SGA newborns are those who weigh less than the 10th percentile for their gestational age, which can be due to intrauterine growth restriction (IUGR) or constitutional factors. SGA newborns may have difficulties with thermoregulation, glucose metabolism, and respiratory function due to inadequate fat stores, glycogen reserves, and surfactant production.
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