A nurse is teaching a client who is at 27 weeks of gestation and has pre-term labor about the signs and symptoms of true labor versus false labor.
Which of the following information should the nurse include in the teaching?
True labor contractions are irregular and subside with rest
False labor contractions are felt in the lower back and radiate to the abdomen
True labor contractions cause cervical dilation and effacement
False labor contractions increase in intensity with ambulation
The Correct Answer is C
True labor contractions cause cervical dilation and effacement.
This means that the cervix opens up and thins out to prepare for the baby’s passage through the birth canal.
Cervical changes can be measured by a pelvic exam.
Choice A is wrong because true labor contractions are regular and do not subside with rest. False labor contractions are irregular and may stop when you change position or activity level.
Choice B is wrong because false labor contractions are usually felt in the front of the abdomen, not in the lower back. True labor contractions may start in the back and radiate to the abdomen.
Choice D is wrong because false labor contractions do not increase in intensity with ambulation. True labor contractions may become stronger and closer together when you walk.
Normal ranges for cervical dilation and effacement vary depending on the stage of labor, but generally, full dilation is 10 cm and full effacement is 100%.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Nifedipine is a calcium channel blocker that is used to relax uterine contractions and postpone preterm labor.However, it can also lower blood pressure and cause side effects such as headache, dizziness, flushing, and palpitations.Therefore, it should be avoided in clients who have cardiac disease or other conditions that affect the heart function.
Choice A is wrong because asthma is not a contraindication for nifedipine.Nifedipine does not affect the airways or cause bronchospasm.
Choice B is wrong because diabetes mellitus is not a contraindication for nifedipine.Nifedipine does not affect blood glucose levels or insulin secretion.
Choice C is wrong because hypertension is not a contraindication for nifedipine.In fact, nifedipine can be used to treat high blood pressure as well as preterm labor.However, blood pressure should be monitored closely during nifedipine therapy to avoid hypotension.
Correct Answer is A
Explanation
Assess the client’s vital signs.
The nurse should first assess the client’s vital signs to determine the severity of the situation and identify any signs of infection, bleeding, or shock.
The nurse should also monitor the fetal heart rate to assess fetal well-being.
Choice B is wrong because a sterile vaginal exam is not indicated for a client who reports lower abdominal cramping and may increase the risk of infection or rupture of membranes.
Choice C is wrong because administering tocolytic medication is not the first action the nurse should take.
Tocolytic medication may be used to inhibit uterine contractions and prolong pregnancy, but only after assessing the client’s and fetus’s condition and obtaining a prescription from the provider.
Choice D is wrong because monitoring the fetal heart rate is not the first action the nurse should take.
Monitoring the fetal heart rate is important to assess fetal well-being, but it does not take priority over assessing the client’s vital signs.
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