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 C

Explanation

A. The tape measure should be placed vertically, not horizontally, over the abdomen to measure fundal height accurately.
B. The client should be in a supine position, not left-lateral, during the measurement.
C. Fundal height is measured from the upper border of the symphysis pubis to the upper border of the uterine fundus.
D. A full bladder can distort the measurement, so the client should have an empty bladder before measuring fundal height.

A. The client rates perineal pain a 3 on a scale of 0 to 10. B. The client's fundus is boggy and deviated to the right C. The client has a moderate amount of lochia rubra D. The client's perineum is ecchymotic with moderate edema

Correct Answer is B

Explanation

A. A pain rating of 3 is relatively mild and does not indicate urinary retention.
B. A boggy, deviated fundus suggests bladder distention, which can occur when the bladder is full and displaces the uterus. This is an indication for straight catheterization to relieve urinary retention.
C. Moderate lochia rubra is expected 4 hours postpartum and does not indicate urinary retention.
D. While edema and bruising are common after delivery, they do not alone indicate a need for catheterization.

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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

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who had a vaginal birth 4 hr ago and had a 3rd-degree perineal laceration with repair. The client has been unable to void since giving birth. Which of the following findings indicates the need for straight catheterization?

Correct Answer is B

Explanation

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