A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor?

Rationale:

A. Take your temperature 1 hour after getting out of bed: Delaying temperature measurement can result in inaccurate readings due to physical activity or environmental changes, making it unreliable for detecting ovulation patterns.

B. Take your temperature every night before going to bed: Basal body temperature (BBT) must be taken in the morning, not at night, because the temperature needs to reflect complete rest, which occurs after several hours of sleep.

C. Take your temperature within 30 minutes after your first morning void: Voiding and moving around before taking your temperature can alter the basal reading, reducing the method’s accuracy for predicting fertile days.

D. Take your temperature immediately after waking and before getting out of bed: BBT should be taken at the same time each morning immediately upon waking and before any activity to ensure the most accurate and consistent readings for fertility tracking.

Rationale for Correct Choices:

• Decreased cardiac output: The client is post–myocardial infarction and experiences chest pain with minimal exertion, tachycardia (HR 112/min), and signs of anxiety and fear. These findings suggest that myocardial function may be compromised. Decreased cardiac output is a significant risk in post-MI clients due to potential for reinfarction, ischemia, or left ventricular dysfunction.
• Respiratory failure: The client has COPD, an elevated respiratory rate (32/min), and oxygen saturation of 87% on room air, which indicates significant hypoxemia. The productive cough, fatigue, and shortness of breath increase the risk for decompensation into respiratory failure without prompt oxygen therapy and pulmonary support.

Rationale for Incorrect Choices:

• Pancytopenia: This condition involves a reduction in red blood cells, white blood cells, and platelets. There is no evidence of bone marrow suppression, recent chemotherapy, or hematologic disorder in this client’s history.
• Neurogenic shock: Neurogenic shock results from spinal cord injury or disruption of sympathetic nervous system control. The client has no evidence of trauma or spinal pathology, and the elevated heart rate contradicts the expected bradycardia of neurogenic shock.
• Hepatic encephalopathy: This is caused by liver dysfunction, typically in clients with advanced liver disease. There are no signs of altered mental status, liver disease, or elevated ammonia levels in this case.