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 B
Explanation
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.
Correct Answer is A
Explanation
Choice A rationale: The rooting reflex is a natural reflex in newborns that helps them find the nipple for feeding. When the baby's cheek is touched or stroked, they will turn their head in that direction and open their mouth, searching for the breast or bottle.
Choice B rationale: The Babinski reflex is a different reflex, which involves the fanning and curling of the toes when the sole of the foot is stroked. It is not related to sucking or feeding.
Choice C rationale: The Moro reflex, also known as the startle reflex, occurs when a newborn is startled by a sudden noise or movement. The baby reacts by extending their arms and legs and then bringing them back toward the center of their body. It is not related to sucking or feeding.
Choice D rationale: The stepping reflex is observed when a newborn is held upright with their feet touching a solid surface. The baby will make stepping movements, but it is not related to sucking or feeding.
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