A nurse is assessing a client who is at 38 weeks of gestation.
Upon admission 2 hours ago, the client had irregular contractions, was dilated 2 cm, and was at -1 cm station. Which of the following findings indicates progression in labor?

The client's contractions persist with walking.

The client reports urinary frequency.

The client has increased blood-tinged vaginal mucus.

The client's station is at -3 cm.

Answer and Explanation

The Correct Answer is A

Choice A rationale

True labor contractions persist and often intensify with activity, such as walking, because physical exertion promotes the release of oxytocin. In contrast, Braxton Hicks or false labor contractions typically diminish or cease with ambulation. Therefore, contractions persisting with walking indicate the cervical changes characteristic of progression into the active phase of labor.

Choice B rationale

Urinary frequency is a common discomfort throughout the third trimester of pregnancy due to the pressure of the enlarged uterus on the bladder. While present, it is not a specific indicator of the progression of labor from the latent to the active phase, which is characterized by measurable changes in cervical dilation and effacement.

Choice C rationale

Increased blood-tinged vaginal mucus, known as "bloody show," results from the cervical capillaries breaking as the cervix effaces and dilates. While this indicates cervical change, the most definitive sign of labor progression is a change in the frequency, duration, and intensity of contractions coupled with measurable descent or cervical dilation increase.

Choice D rationale

The station is the relationship of the presenting part to the ischial spines (zero station). The client's initial station was -1 cm. A change to -3 cm station indicates the fetus has moved up and away from the ischial spines, which signifies regression, or higher negative numbers, in the engagement, not the desired progression into the maternal pelvis.

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Correct Answer is ["A","E"]

Explanation

Choice A rationale

The Diphtheria-tetanus-acellular pertussis (Tdap) vaccine is recommended during each pregnancy, ideally between 27 and 36 weeks of gestation. This timing is crucial because it allows for the maternal production and optimal transplacental transfer of pertussis antibodies to the fetus. These antibodies provide crucial passive immunity to the newborn against pertussis (whooping cough), which is a severe and potentially fatal disease in infants before they can be directly immunized.

Choice B rationale

The Human papillomavirus (HPV) vaccine is not recommended during pregnancy because there is limited safety data regarding its use in pregnant women. While it is not known to cause adverse fetal effects, it is a recombinant vaccine and, as a precautionary measure, it should be delayed until the postpartum period. Routine HPV vaccination is typically administered to adolescents and young adults up to age 26.

Choice C rationale

The Varicella vaccine is a live attenuated virus vaccine and is contraindicated in pregnancy due to the theoretical risk of transmission of the live virus to the fetus, which could potentially cause congenital varicella syndrome. Women who are non-immune to varicella should receive this vaccine postpartum, before being discharged from the hospital, to protect future pregnancies.

Choice D rationale

The Measles, mumps, and rubella (MMR) vaccine is a live attenuated virus vaccine and is contraindicated in pregnancy due to the theoretical risk of fetal infection and subsequent congenital abnormalities, particularly from the rubella component. Women who are not immune to rubella should be vaccinated postpartum and advised to avoid conception for about one month following vaccination.

Choice E rationale

The inactivated influenza (flu shot) vaccine is recommended for all women who are pregnant during the flu season, regardless of their stage of gestation, including at 30 weeks. This is a killed virus vaccine and is considered safe in pregnancy. It protects the mother from severe influenza illness and also provides the newborn with passive immunity in the initial months of life.

A. Irritability B. Pupil response C. Milia on nose and cheeks D. Lanugo on bilateral shoulders E. Axillary temperature F. Respiratory rate G. Apical heart rate H. Lung findings I. Stool characteristics J. Abdomen findings

Correct Answer is ["A","E","F"]

Explanation

Body System	Finding	Interpretation	Report to Provider?
Neurologic	Irritability	Can be normal if mild, but persistent irritability may indicate hypoglycemia, hypocalcemia, withdrawal, or infection → concerning	✅ Yes
	Pupil response (brisk, equal)	Normal neuro finding	❌ No
Integumentary	Milia on nose/cheeks	Benign, normal newborn finding	❌ No
	Lanugo on shoulders	Normal in preterm/term newborns	❌ No
Cardiopulmonary	Axillary temperature 36.2°C (97.2°F)	Low temp (normal 36.5–37.5°C). Hypothermia can indicate infection, poor thermoregulation	✅ Yes
	Respiratory rate 80/min	Tachypnea (normal 30–60/min). May indicate respiratory distress, sepsis, metabolic issue	✅ Yes
	Apical heart rate 158/min	Normal (110–160/min)	❌ No
	Lung findings (clear)	Normal	❌ No
Gastrointestinal	Stool characteristics (meconium, normal)	Normal	❌ No
	Abdomen findings (not abnormal)	Normal	❌ No

🧾 Explanation

Irritability: While some fussiness is expected, persistent irritability is a red flag for metabolic or infectious causes.
Temperature 36.2°C: Below normal → newborn hypothermia, which can worsen quickly.
Respiratory rate 80/min: Markedly elevated → tachypnea, possible respiratory distress or sepsis.
Other findings (milia, lanugo, brisk pupils, HR 158, clear lungs, normal stool) are expected newborn variations and do not require reporting.

✅ Final Answer: The nurse should report:

Neurologic: Irritability
Cardiopulmonary: Axillary temperature 36.2°C
Cardiopulmonary: Respiratory rate 80/min

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A nurse is assessing a client who is at 38 weeks of gestation. Upon admission 2 hours ago, the client had irregular contractions, was dilated 2 cm, and was at -1 cm station. Which of the following findings indicates progression in labor?

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Explanation

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A nurse is assessing a client who is at 38 weeks of gestation.
Upon admission 2 hours ago, the client had irregular contractions, was dilated 2 cm, and was at -1 cm station. Which of the following findings indicates progression in labor?