A nurse is attending to a first-time pregnant woman who is at term.
She is experiencing contractions but is unsure if she is in labor.
Which of the following should the nurse identify as a labor sign?
The position of the presenting part.
Membrane rupture.
Contraction pattern.
Changes in the cervix.
The Correct Answer is D
Choice D rationale
Changes in the cervix, including effacement (thinning) and dilation (opening), are reliable signs of true labor. During true labor, contractions cause the cervix to thin and open to prepare for the passage of the baby. This is in contrast to Braxton Hicks contractions, or “false labor,” which are irregular and do not result in changes to the cervix.
Choice A rationale
The position of the presenting part can provide information about the progress of labor and the likely need for interventions, but it is not a definitive sign of labor.
Choice B rationale
Membrane rupture, or “water breaking,” can occur before or during labor. However, not all women experience a noticeable rupture of membranes, and sometimes the fluid can leak slowly, making it less noticeable.
Choice C rationale
A regular contraction pattern can be a sign of labor, but contractions can also occur in patterns during false labor. Therefore, contraction pattern alone is not a definitive sign of labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is []
Explanation
The client is most likely experiencing Normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.
Actions: The nurse should:
1. Encourage the client to push during contractions. This will help the baby move down the birth canal.
2. Monitor fetal heart rate. This is crucial to ensure the baby is not in distress.
Parameters: The nurse should monitor:
1. Frequency of contractions. This will help assess the progress of labor.
2. Fetal heart rate. Any abnormalities could indicate fetal distress, which would require immediate medical attention.
Correct Answer is C
Explanation
Choice A reason:
Fetal head compression is associated with early decelerations, not late. Early decelerations are a normal finding during labor as the fetal head is compressed during contractions, leading to a vagal response that temporarily decreases the heart rate.
Choice B reason:
Umbilical cord compression leads to variable decelerations, not late. Variable decelerations can occur at any time during the contraction cycle and are caused by compression of the umbilical cord, which can restrict blood flow to the fetus.
The correct answer is C. Uteroplacental insufficiency.
Late decelerations are indicative of uteroplacental insufficiency, which is a condition where the placenta is not delivering enough oxygen and nutrients to the fetus.
Choice D reason:
Maternal bradycardia, which is a slower than normal heart rate in the mother, does not cause late decelerations in the fetus. Instead, maternal bradycardia can be a separate concern and does not directly affect the fetal heart rate pattern observed on the monitor.
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