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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale: While gestational hypertension can have various implications for the mother and baby, it is not directly associated with an increased risk of postpartum hemorrhage.
Choice B rationale: The birth of a small-for-gestational-age newborn may have certain implications, but it is not directly associated with an increased risk of postpartum hemorrhage.
Choice C rationale: Precipitous birth, which refers to an extremely rapid labor and delivery lasting less than 3 hours, is a risk factor for postpartum hemorrhage. Rapid delivery can lead to incomplete uterine contractions and inadequate uterine tone, increasing the risk of excessive bleeding after birth.
Choice D rationale: A two-vessel umbilical cord, also known as a single umbilical artery, may be associated with certain fetal anomalies but is not directly related to an increased risk of postpartum hemorrhage.

A. Repeat the contraction stress test in 24 hr. B. Prepare the client for admission to the hospital. C. Check the client's cervix for dilation. D. Document the findings as expected in the client records.

Correct Answer is B

Explanation

Choice A rationale: A positive contraction stress test warrants immediate attention and evaluation. Waiting for 24 hours to repeat the test could delay necessary interventions in case of fetal distress.
Choice B rationale: A positive contraction stress test indicates that there are late decelerations in the baby's heart rate during contractions, which may suggest fetal distress. In such cases, it is essential to admit the client to the hospital for further evaluation, monitoring, and appropriate management.
Choice C rationale: Checking the client's cervix for dilation is not the most appropriate action in response to a positive contraction stress test. Fetal well-being and assessment take priority in this situation.
Choice D rationale: A positive contraction stress test requires further action and should not be considered a routine finding. Proper management and evaluation are necessary when the test results are positive.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

Correct Answer is C

Explanation

A nurse is caring for a client who is at 38 weeks of gestation and has a positive contraction stress test. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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