A client at 38 weeks gestation presents to OB triage complaining of contractions for 2 hours.
How can the nurse best assess for true labor?
Assess for fetal lightening.
Ask the client about relief with ambulation.
Assess contraction frequency.
Check for cervical change.
The Correct Answer is D
Differentiating between true and false labor involves assessing physical changes in the reproductive system. Nurses must apply knowledge of cervical effacement and dilation. True labor is defined specifically by progressive changes in the cervix regardless of contraction patterns.
Choice A rationale
Lightening occurs when the fetal head descends into the pelvic inlet, often happening weeks before labor in primigravidas. While it indicates readiness for labor, it does not confirm that active, true labor has actually begun.
Choice B rationale
False labor contractions, or Braxton Hicks, often diminish with activity or position changes. While this assessment provides subjective data about the nature of the discomfort, it is not a definitive diagnostic indicator of true labor.
Choice C rationale
Contraction frequency and intensity can be regular in both true labor and prodromal labor. Relying solely on the timing of contractions is less reliable than physical evidence of cervical progress when diagnosing active labor.
Choice D rationale
The hallmark of true labor is progressive cervical effacement and dilation. Assessing the cervix through a manual exam provides objective evidence that the uterine contractions are effective and that the birthing process is definitively underway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Priority assessment in obstetrics focuses on fetal well-being and identifying life-threatening complications. Clinical knowledge regarding fetal kick counts and placental perfusion must be applied to differentiate between normal physiological changes of pregnancy and signs of impending fetal compromise or demise.
Choice A rationale
Back pain is a common discomfort in pregnancy caused by shifts in the center of gravity and lumbar lordosis. While uncomfortable, it is not a priority finding compared to indicators of direct fetal distress or placental issues.
Choice B rationale
Decreased fetal movement is a critical sign of potential fetal hypoxia or distress. Fetal activity typically remains consistent, and a quiet baby requires immediate assessment via non-stress testing or ultrasound to ensure the fetus is still viable.
Choice C rationale
Varicosities in the lower extremities are common due to increased venous pressure from the enlarging uterus. While they require management like compression stockings, they do not pose an immediate threat to the life of the mother or fetus.
Choice D rationale
Increased fundal height can indicate polyhydramnios or macrosomia but is generally assessed over time. It does not carry the same immediate urgency as a sudden change in fetal movement, which suggests an acute oxygenation problem.
Correct Answer is A
Explanation
This emergency department scenario requires applying knowledge of cardiovascular pharmacology and drug-to-drug interactions. Identifying contraindications for nitroglycerin is critical to prevent life-threatening hypotension, making the history of phosphodiesterase inhibitor use the most vital information for the provider.
Choice A rationale
Sildenafil is a phosphodiesterase inhibitor that causes significant vasodilation. When combined with nitroglycerin, it can lead to profound, irreversible hypotension and cardiovascular collapse. This interaction is a direct contraindication to administering nitrates for chest pain.
Choice B rationale
Smoking history is a significant risk factor for coronary artery disease but does not pose an immediate pharmacological contraindication to the ordered emergency medications. It is relevant for long-term care but not the immediate priority.
Choice C rationale
A positive HIV status is important for the client's overall medical history and universal precautions but does not interact with oxygen, aspirin, or nitroglycerin. It is not the priority report for acute chest pain management.
Choice D rationale
Low sperm count is a reproductive health issue and has no relevance to the emergency management of myocardial ischemia. It does not affect the safety or efficacy of the medications ordered for chest pain.
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