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
Related Questions
Correct Answer is C
Explanation
If a patient in labor at 40 weeks of gestation reports saturating two perineal pads in the past 30 minutes, and placenta previa is suspected, an appropriate nursing action would be to prepare for a cesarean birth. Placenta previa, where the placenta partially or completely covers the cervical opening, can cause significant bleeding and is typically managed with a cesarean delivery to prevent further bleeding and ensure the safety of the mother and baby.
Correct Answer is A
Explanation
Step 1 is to calculate the volume of Toradol to be drawn up. Toradol is available in 60 mg/mL. Therefore, to administer a dose of 30 mg, the nurse would need to draw up 30 mg ÷ 60 mg/mL = 0.5 mL.
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