At the midpoint of pregnancy, you review the beginning signs of labor with a patient. Which of the following would you include as a beginning sign of labor?
Excessive fatigue and headache.
A sudden gush of clear fluid from the vagina.
Sharp, right-sided abdominal pain.
An increased pulse rate and upper abdominal pain.
The Correct Answer is B
Choice A rationale
While excessive fatigue and headache can occur in pregnancy, they are not typically signs of labor.
Choice B rationale
A sudden gush of clear fluid from the vagina, also known as rupture of membranes, is a sign that labor may be starting.
Choice C rationale
Sharp, right-sided abdominal pain is not a typical sign of labor. It could indicate other issues such as appendicitis.
Choice D rationale
An increased pulse rate and upper abdominal pain are not typical signs of labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While the anterior fontanel being soft and level is an important observation in a newborn, it is not typically used as part of a gestational age assessment.
Choice B rationale
The presence of plantar creases covering 3 of the sole is a typical finding in a full-term newborn and is used as part of a gestational age assessment.
Choice C rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is a common finding in newborns, especially shortly after birth. However, it is not typically used as part of a gestational age assessment.
Choice D rationale
Vernix caseosa in the inguinal creases can be a sign of a preterm newborn, as vernix caseosa is typically present in larger amounts in preterm newborns. However, it is not typically used as part of a gestational age assessment.
Correct Answer is A
Explanation
Choice A rationale
When the fetal head is at 3+ station, it means that the baby’s head has moved down the birth canal and is very close to the vaginal opening. At this stage, the nurse should observe for crowning, which is when the widest part of the baby’s head can be seen at the vaginal opening. This is a critical time during labor, and the nurse needs to be prepared for the delivery of the baby.
Choice B rationale
Applying fundal pressure is not recommended as it can cause complications such as uterine rupture, fetal distress, and maternal discomfort. It is also not necessary when the fetal head is at 3+ station as the baby is already moving down the birth canal.
Choice C rationale
Oxytocin is a hormone that can stimulate uterine contractions. However, it is not necessary to prepare to administer oxytocin when the fetal head is at 3+ station. At this stage, the mother’s body is already effectively progressing through labor.
Choice D rationale
Observing for the presence of a nuchal cord, which is when the umbilical cord is wrapped around the baby’s neck, is important throughout labor. However, it is not the primary action the nurse should take when the fetal head is at 3+ station.
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