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?

Contraction intensity increased by ambulation

Slow change in dilation and effacement

Presence of bloody show

Intermittent painless contractions

Answer and Explanation

The Correct Answer is D

A. Contraction intensity increased by ambulation. This finding is typical of true labor, as walking or changing positions usually causes contractions to increase in strength, duration, and frequency. In contrast, false labor contractions often subside with rest or activity changes and do not intensify with movement.
B. Slow change in dilation and effacement. Any change in cervical dilation or effacement, even if slow, is more consistent with true labor. False labor does not produce any significant cervical change, and the cervix remains closed or minimally altered with time or contractions.
C. Presence of bloody show. Bloody show is the expulsion of the mucus plug mixed with blood, a common sign of cervical softening and dilation. This is a key indicator of true labor, as it reflects actual physical changes in preparation for delivery.
D. Intermittent painless contractions. These contractions, also called Braxton Hicks contractions, are a hallmark of false labor. They are usually irregular, mild, and do not lead to cervical changes. They often resolve with hydration, rest, or position changes and are considered a normal part of the body's preparation for labor, not the onset of true labor.

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Correct Answer is A

Explanation

A. "I will use a communication board to assess the client's needs." This demonstrates appropriate use of assistive tools tailored for individuals with visual impairments. Communication boards can include tactile or auditory features, allowing clients to express needs effectively without relying on vision.
B. “I will collaborate with a speech therapist about the client's plan of care." While speech therapy may be helpful in some situations, it is not directly related to communication strategies for a client with visual impairment unless there is a concurrent speech or language issue.
C. "I will use indirect lighting in the client's room." Indirect lighting can reduce glare, which may help clients with partial vision, but this action does not address communication needs or strategies specific to visual impairment.
D. “I will use a loud tone of voice when speaking with the client.” Clients with visual impairments do not necessarily have hearing impairments. Raising the voice unnecessarily can be perceived as patronizing or inappropriate unless hearing loss is also present.

A. Heart rate B. Sleep pattern C. Hallucinations D. skin turgor E. Hygiene

Correct Answer is ["A","C","D","E"]

Explanation

A. Heart rate. The client has a heart rate of 120/min, which is tachycardia and may indicate dehydration, mania-related hyperactivity, or a response to poor nutritional status. This requires immediate follow-up to assess for cardiovascular strain or fluid imbalance.
B. Sleep pattern. While lack of sleep is concerning and a clear symptom of mania, it is a behavioral health issue that typically does not require immediate physiological intervention unless it leads to severe exhaustion or psychosis. It should be addressed, but is not the top priority.
C. Hallucinations. The client is responding to internal stimuli, indicating active psychosis, which poses a safety risk to the client and others. Hallucinations require immediate intervention to stabilize mental health and prevent harm.
D. Skin turgor. Poor skin turgor suggests dehydration, which is a priority physiological concern, especially when paired with tachycardia and failure to recall last food intake. This finding indicates the need for fluid and electrolyte evaluation and possible replacement.
E. Hygiene. The client's unclean appearance reflects self-neglect, a common feature of psychiatric decompensation, and may indicate inability to meet basic needs. This requires prompt attention to prevent complications like infection and assess for functional impairment, though it is secondary to life-threatening physiological or safety concerns.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing effective communication techniques for a client who has visual impairment with a newly licensed nurse. Which of the following statements by the nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client. Exhibits The nurse is assessing the client. Select the 4 findings that require immediate follow-up.

Correct Answer is ["A","C","D","E"]

Explanation

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