Aureissisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirms that the client is in labor?
Fain just above the navel
Cervical dilation
Amniotic fluid in the vaginal vault
Contractions every 3 to 4 min
The Correct Answer is B
Choice A rationale: Pain above the navel is not a specific indicator of labor and may be unrelated to the onset of labor.
Choice B rationale: Cervical dilation is a definitive sign of labor. It indicates that the cervix is opening to allow the baby's passage through the birth canal.
Choice C rationale: The presence of amniotic fluid in the vaginal vault (rupture of membranes) could indicate that the client's water has broken, but it does not confirm active labor. Labor can begin before or after the rupture of membranes.
Choice D rationale: Regular contractions are a typical sign of labor, but their frequency alone does not confirm active labor. Other signs, such as cervical dilation and effacement, are necessary to confirm active labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Turning the client onto her left side is a common measure to improve fetal oxygenation and is often used during labor. However, in this scenario, the nurse needs to address the absence of fetal movement during the nonstress test.
Choice B rationale:
Encouraging the client to walk around and then resume monitoring is not appropriate when there is a concern about the absence of fetal movement during the nonstress test.
Choice C rationale:
Vibroacoustic stimulation involves using sound stimulation to elicit fetal movement. If there has been no fetal movement during the nonstress test, this intervention can be used to assess fetal well-being and provoke a response from the fetus.
Choice D rationale:
Preparing the client for induction of labor is not indicated based solely on the absence of fetal movement during a nonstress test. Further assessment and interventions are needed before considering induction.
Correct Answer is A
Explanation
Choice A rationale: Misoprostol is a prostaglandin analog and is contraindicated for use during labor at 32 weeks of gestation as it can lead to uterine hyperstimulation, which may pose a risk to the preterm fetus.
Choice B rationale: Folic acid is a vitamin supplement and is not contraindicated during labor. However, it is typically taken earlier in pregnancy to prevent neural tube defects.
Choice C rationale: Nifedipine is a calcium channel blocker that may be used to suppress preterm labor, and it is not contraindicated at 32 weeks of gestation.
Choice D rationale: Terbutaline is a beta-adrenergic agonist that may be used to relax the uterine smooth muscles and inhibit preterm labor. It is not contraindicated at 32 weeks of gestation.
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