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 ["A","B","C"]
Explanation
Choice A rationale: The Scarf sign assesses the range of motion of the newborn's shoulder and elbow joint. It measures the ability of the newborn's arm to be brought across the chest.
Choice B rationale: Arm recoil measures the degree of resistance and recoil of the newborn's arm when it is extended and then flexed against the chest. This reflex provides information about the newborn's muscle tone and neuromuscular maturity.
Choice C rationale: The Moro reflex, also known as the startle reflex, is elicited by a sudden change in the newborn's position or by a loud noise. It involves an initial extension and abduction of the arms, followed by a flexion and adduction. This reflex helps assess the newborn's neurologic and neuromuscular maturity.
Choice D rationale: "Heel to ear" is not a standard neuromuscular assessment used in the gestational age assessment. It may be an incorrect or unclear term.
Choice E rationale: The popliteal angle is not a neuromuscular assessment used in the gestational age assessment. It measures the angle of flexion in the knee joint and is not directly related to neuromuscular maturity
Correct Answer is D
Explanation
Choice A rationale: Applying identification bands is an essential step in newborn care, but it is not the priority immediately after delivery. The nurse should first address the baby's physiological needs, such as drying and maintaining body temperature.
Choice B rationale: Assessing and documenting the Apgar score is important for evaluating the newborn's overall condition and response to delivery, but it is not the priority immediately after delivery.
Choice C rationale: Administering phytonadione (vitamin K) to prevent bleeding disorders in the newborn is essential, but it can be done after drying and stabilizing the baby's body temperature.
Choice D rationale: After ensuring a patent airway, the nurse's priority should be to dry the newborn. Drying the newborn is important for maintaining body temperature and preventing heat loss, especially during the immediate post-delivery period. Wet newborns can lose heat rapidly through evaporation, so drying the baby helps prevent hypothermia and stabilize the baby's body temperature.
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