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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"}}
Explanation
🧾 Explanation
- Moderate lochia rubra
- Normal up to 1–2 weeks postpartum. Not related to mastitis.
- Temperature 38.4°C
- Still febrile after 24 hrs of antibiotics → infection not yet controlled.
- Purulent nipple discharge
- New finding. Indicates possible breast abscess or worsening mastitis.
- Hemoglobin 12 g/dL
- Stable and within normal range. Not relevant to mastitis progression.
- WBC 35,000/mm³
- Increased from 28,000 → worsening systemic inflammatory response.
- Decreased pain
- Symptomatically better, but this may reflect partial relief from antibiotics/analgesics rather than full resolution. Still, it’s a positive sign.
Summary:
- Improving: Pain relief.
- Unrelated: Lochia rubra, hemoglobin.
- Worsening: Persistent fever, purulent nipple discharge, rising WBC.
This mixed picture suggests partial response but possible complication (breast abscess). The nurse should notify the provider promptly, anticipate breast ultrasound to rule out abscess, and continue close monitoring.
Correct Answer is C
Explanation
Choice A rationale: Trendelenburg position, where the client is placed with the head lower than the feet, is not appropriate in this scenario. This position is typically used for procedures requiring pelvic exposure or in cases of air embolism. It does not optimize uteroplacental perfusion and may actually compromise maternal respiratory function in late pregnancy due to diaphragmatic pressure from the gravid uterus. Therefore, it is not the correct position following prostaglandin insertion.
Choice B rationale: Knee-chest position is used in obstetric emergencies such as umbilical cord prolapse to relieve pressure on the cord and improve fetal oxygenation. It is not indicated for cervical ripening or for optimizing uteroplacental perfusion. Maintaining this position would be uncomfortable and unnecessary for the client, and it does not aid in medication absorption. Thus, it is not the correct intervention in this context.
Choice C rationale: Lateral tilt, specifically left lateral or side-lying tilt, is the correct position. This position reduces compression of the inferior vena cava by the gravid uterus, thereby improving venous return, cardiac output, and uteroplacental perfusion. It also facilitates optimal absorption of the vaginal prostaglandin insert by keeping the medication in place. This is the evidence-based nursing intervention following prostaglandin administration for cervical ripening.
Choice D rationale: Lithotomy position is used primarily for vaginal examinations, procedures, or delivery. It is not appropriate for maintaining medication absorption or optimizing uteroplacental perfusion. Prolonged lithotomy positioning increases maternal discomfort and risk of venous stasis. Since the client is not undergoing delivery or a procedure requiring pelvic exposure, this position is not indicated after prostaglandin insertion.
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