A nurse is caring for a client in OB triage who is a primigravida, at term, reporting low back pain radiating to the lower abdomen every 5 minutes for 2 hours. The client states, "I am not really sure if I'm in labor or not." Which of the following should the nurse recognize as a sign of true labor?
Contractions stop with comfort measures
Rupture of membranes
Regular contractions with cervical change
Station of the presenting part
The Correct Answer is C
Choice A reason: Contractions that stop with comfort measures such as rest, hydration, or position change are characteristic of false labor. They do not indicate true labor.
Choice B reason: Rupture of membranes can occur in both true and false labor. While it may signal impending delivery, it is not by itself diagnostic of true labor.
Choice C reason: True labor is defined by regular contractions that lead to progressive cervical dilation and effacement. Cervical change is the hallmark of true labor, distinguishing it from false labor.
Choice D reason: The station of the presenting part indicates fetal descent but does not confirm true labor. Descent can occur without cervical change, so it is not the defining feature of true labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A reassuring fetal heart tracing indicates normal fetal oxygenation and wellbeing. This is not a concern and requires no immediate intervention.
Choice B reason: A continuous contraction lasting 2 minutes is abnormal and dangerous. Normal contractions should last 45–90 seconds. Prolonged contractions reduce uteroplacental blood flow, increasing the risk of fetal hypoxia and uterine rupture. This finding requires immediate reporting and intervention.
Choice C reason: Contractions occurring every 4 minutes are within normal labor progression. This is not concerning unless accompanied by abnormal fetal heart patterns or maternal distress.
Choice D reason: A pink mucus plug is a normal sign of cervical change and impending labor. It is expected and not a cause for concern.
Correct Answer is C
Explanation
Choice A reason: Contractions that stop with comfort measures such as rest, hydration, or position change are characteristic of false labor. They do not indicate true labor.
Choice B reason: Rupture of membranes can occur in both true and false labor. While it may signal impending delivery, it is not by itself diagnostic of true labor.
Choice C reason: True labor is defined by regular contractions that lead to progressive cervical dilation and effacement. Cervical change is the hallmark of true labor, distinguishing it from false labor.
Choice D reason: The station of the presenting part indicates fetal descent but does not confirm true labor. Descent can occur without cervical change, so it is not the defining feature of true labor.
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