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 C
Explanation
Rationale:
A. Coarse lung sounds: Coarse lung sounds are typically associated with pulmonary issues such as fluid overload or pneumonia. They are not specific to cardiac tamponade and may appear later or not at all in this condition.
B. Widening pulse pressure: Cardiac tamponade causes narrowing of the pulse pressure due to decreased stroke volume, not widening. A narrowing pulse pressure is a more reliable hemodynamic sign of tamponade.
C. Muffled heart sounds: Muffled or distant heart sounds are a classic early sign of cardiac tamponade. They result from fluid accumulation in the pericardial sac, which insulates the heart and dampens the transmission of sound.
D. Decreased jugular vein distention: Cardiac tamponade typically causes increased jugular vein distention due to impaired venous return to the heart. A decrease in JVD would not be expected and may indicate a different process.
Correct Answer is A
Explanation
Rationale:
A. First-degree atrioventricular block: A first-degree AV block is characterized by a prolonged but consistent P-R interval greater than 0.20 seconds. A P-R interval of 0.35 seconds with no dropped beats is a classic sign of this dysrhythmia.
B. Atrial fibrillation: Atrial fibrillation presents with an irregularly irregular rhythm and absent distinct P waves. The presence of a consistent P-R interval rules out atrial fibrillation.
C. Premature atrial complexes: PACs are identified by early P waves that may look different from sinus P waves, often followed by a normal QRS complex. They do not cause consistently prolonged P-R intervals.
D. Complete heart block: Complete (third-degree) heart block involves no association between P waves and QRS complexes. The atria and ventricles beat independently, which contradicts the presence of a consistent P-R interval.
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