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?
Slow change in dilation and effacement
Contraction intensity increased by ambulation
Presence of bloody show
Intermittent, painless contractions
The Correct Answer is D
Rationale:
A. Slow change in dilation and effacement: Even slow cervical changes are indicative of true labor. False labor does not cause any progressive cervical dilation or effacement, making this an inconsistent finding for false labor.
B. Contraction intensity increased by ambulation: In true labor, contractions typically intensify with activity such as walking. In contrast, false labor contractions often diminish or resolve with changes in position or ambulation.
C. Presence of bloody show: Bloody show results from cervical dilation and the disruption of cervical capillaries. It is a hallmark of true labor and would not be expected during false labor.
D. Intermittent, painless contractions: False labor is characterized by irregular, non-progressive, and typically painless contractions, often referred to as Braxton Hicks contractions. These are normal in late pregnancy but do not indicate true labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Rationale:
A. Possible alternative treatments: The provider is responsible for informing the client about all viable treatment options. This allows the client to make an informed decision by weighing the benefits and risks of each option.
B. Expected outcome of the procedure: Clients must understand the intended benefits and goals of the procedure. This helps them form realistic expectations and evaluate whether the procedure aligns with their preferences and values.
C. Explanation of the procedure: A clear and complete description of the procedure must be provided, including what it involves and how it will be performed. This is essential for valid informed consent.
D. Cost of the procedure: While important for financial planning, cost information is typically handled by billing or administrative staff, not required for medical informed consent by the provider.
E. Potential complications: Clients need to be informed about potential risks and complications to fully understand the implications of undergoing the procedure. This disclosure is legally and ethically required for consent.
Correct Answer is B
Explanation
Rationale:
A. Bradycardia: Bradycardia is not a typical adverse effect of IV fluid therapy. If anything, fluid overload might contribute to hypertension or reflex tachycardia rather than a slowing of the heart rate.
B. Distended neck veins: Distended neck veins are a common sign of fluid volume overload, a potential adverse effect of IV therapy. This occurs when excess fluid increases venous pressure and can indicate worsening heart function or pulmonary congestion.
C. Weight loss: IV fluid therapy is expected to increase or stabilize weight due to fluid retention, not cause weight loss. Weight loss might instead indicate dehydration or catabolic states, not an adverse reaction to fluid infusion.
D. Bradypnea: Bradypnea is not typically caused by IV fluid therapy. In fluid overload, the more common respiratory symptom is tachypnea or dyspnea due to pulmonary congestion, not a slowed respiratory rate.
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