A nurse is assessing a client who is at 38 weeks of gestation. Upon admission 2 hr 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 reports urinary frequency.

The client has increased blood-tinged vaginal mucus.

The client's station is at 3 cm.

The client's contractions ease with walking

Answer and Explanation

The Correct Answer is B

A. Urinary frequency is common in pregnancy but does not indicate labor progression.
B. Increased blood-tinged vaginal mucus (bloody show) indicates cervical dilation and labor progression.
C. Station is measured in centimeters but ranges from -3 to +3 relative to the ischial spines, so "3 cm" station is unclear and likely incorrect terminology.
D. Contractions easing with walking suggest false labor rather than progression.

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Correct Answer is ["A","B","D"]

Explanation

A. Double-flush the toilet with the lid closed – Methotrexate is a hazardous medication that is excreted in body fluids. The client should be instructed to double-flush the toilet with the lid closed for 48 hours to prevent exposure to others.

B. Avoid sexual intercourse until the β-hCG level is undetectable – This reduces the risk of rupture or bleeding and prevents confusion with another pregnancy. Abstinence is recommended until the ectopic pregnancy is fully resolved.

C. Take aspirin as needed for pain – Aspirin is contraindicated as it increases the risk of bleeding and can interact adversely with methotrexate, enhancing toxicity.

D. Avoid exposure to the sun – Methotrexate can cause photosensitivity, and the client should use sunscreen and protective clothing when outdoors.

E. Expect a transient fever and chills – Fever and chills are not expected side effects of methotrexate. These symptoms may indicate infection or rupture and should be reported immediately.

A. "Plan to spend individual time with your preschooler." B. "Move your preschooler from their crib to a bed the day before the baby comes home." C. "Ensure that your preschooler sees you holding the baby during the initial encounter" D. "Avoid bringing your preschooler to prenatal visits."

Correct Answer is A

Explanation

A. Spending individual time with the preschooler helps reduce feelings of jealousy and promotes security during the transition.
B. Moving the child too close to the arrival of the new baby can increase stress; it’s better to make such changes well in advance.
C. The preschooler might feel excluded or jealous if they see the parent holding the baby first; it is better to prepare them beforehand.
D. Including the preschooler in prenatal visits can help them feel involved and less anxious about the new sibling.

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A nurse is assessing a client who is at 38 weeks of gestation. Upon admission 2 hr 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?

Nursing Test Bank

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Explanation

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Correct Answer is A

Explanation

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