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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: RhoGAM is not given solely based on blood loss. It is administered to prevent Rh isoimmunization, which is unrelated to the amount of blood loss.
Choice B rationale: If the client has previously given birth to an Rh-negative infant, she is already sensitized and would not require RhoGAM for this current ectopic pregnancy.
Choice C rationale: Rho(D) Immune globulin (RhoGAM) is given to Rh-negative individuals to prevent the development of Rh isoimmunization, which could occur if the client is exposed to Rh-positive blood. In the case of an ectopic pregnancy, there may be a possibility of fetal blood mixing with the mother's bloodstream, which could lead to sensitization in an Rh-negative individual.
Choice D rationale: The desire to conceive again does not dictate the need for RhoGAM. It is solely based on the client's Rh factor status and the potential for sensitization during the ectopic pregnancy.
Correct Answer is D
Explanation
Choice A rationale:
Massaging the area is not recommended because the client's symptoms could indicate a possible deep vein thrombosis (DVT), and massaging could dislodge a clot and cause harm.
Choice B rationale:
Applying cold compresses is not recommended if DVT is suspected, as it could potentially worsen the condition.
Choice C rationale:
Flexing the knee while resting is not recommended if DVT is suspected, as it could potentially worsen the condition and increase the risk of a clot traveling to the lungs (pulmonary embolism).
Choice D rationale:
Elevating the leg can help reduce swelling and improve blood flow. However, the client should still see the provider for further evaluation of possible DVT.
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