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 C

Explanation

A. "You should take a dose every night at bedtime." Sublingual nitroglycerin is not taken on a routine schedule like bedtime. It is used as needed at the onset of chest pain or before activities that might trigger angina, not as a preventive nightly dose.
B. “You should take this medication with food." Sublingual nitroglycerin is placed under the tongue and absorbed directly into the bloodstream, bypassing the gastrointestinal system. It does not require administration with food.
C. "You may repeat a dose after five minutes." If chest pain persists after the first dose, the client may take one tablet every 5 minutes, up to a total of three doses within 15 minutes. If the pain continues after the third dose, emergency services should be contacted.
D. “You may crush this medication if needed." Sublingual tablets should never be crushed or swallowed, as this would prevent proper absorption through the oral mucosa and reduce the medication’s effectiveness in relieving acute chest pain.

A. Aspirin 1 tablet daily B. Furosemide 20 mg BID C. Nitroglycerin transdermal patch D. Metoprolol 5 mg now

Correct Answer is B

Explanation

A. Aspirin 1 tablet daily. This prescription is incomplete because it does not specify the dose in milligrams. Aspirin comes in multiple strengths, and clarity is essential to ensure safe administration.
B. Furosemide 20 mg BID. This prescription is complete because it includes the medication name, dosage (20 mg), and frequency (twice daily). It provides all necessary components for safe administration.
C. Nitroglycerin transdermal patch. This order lacks critical details such as the dosage, frequency, and duration of use. Without this information, the prescription is incomplete and cannot be safely implemented.
D. Metoprolol 5 mg now. Although it includes the medication, dosage, and timing, it does not specify the route (e.g., oral, IV), which is necessary for the prescription to be considered complete.

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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

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