After an amniotomy, which action by the nurse takes priority?

Choice A reason:

Rupture of the membranes is not a reliable sign of true labor, as it can occur before or during labor, or be artificially induced by the provider. • Choice B reason:

Patterns of contractions can vary depending on the stage and phase of labor, and can also be influenced by factors such as hydration, activity, and medication. Contractions alone do not indicate true labor unless they are accompanied by cervical changes. • Choice C reason:

Changes in the cervix, such as effacement (thinning) and dilation (opening), are the most accurate indication of true labor. Cervical changes are caused by the pressure of the presenting part and the force of the contractions. The nurse should assess the cervix periodically to determine the progress of labor. • Choice D reason:

The station of the presenting part refers to the relationship of the fetal head to the maternal ischial spines, which are bony landmarks in the pelvis. The station can range from -5 (high) to +5 (low), with 0 being at the level of the ischial spines. Station does not indicate true labor, as it can vary depending on the parity, pelvic shape, and fetal position of the client.

A. Human placental lactogen (hPL) is a hormone produced by the placenta that helps regulate the metabolism of the mother and fetus, but it is not used as the basis for pregnancy tests. It plays a role in modulating the metabolic state of the mother during pregnancy to facilitate the energy supply of the fetus.

B. Estrogen (estriol) is another hormone produced by the placenta, which is important for maintaining pregnancy and preparing the body for childbirth. However, it is not the hormone detected by pregnancy tests. Estriol levels increase significantly during pregnancy but are not used as a marker for pregnancy tests.

C. Progesterone (progestin) is crucial for maintaining the uterine lining and supporting early pregnancy. While it is essential for a successful pregnancy, it is not the hormone that pregnancy tests detect. Progesterone helps prevent uterine contractions and supports the endometrium.

D. Human chorionic gonadotropin (hCG) is the hormone detected by pregnancy tests. It is produced by the placenta shortly after the embryo attaches to the uterine lining. The presence of hCG in the blood or urine is a reliable indicator of pregnancy, which is why it is the basis for pregnancy tests.