A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor.
Which of the following findings confirm to the nurse that the client is in labor?.

The correct answer is choice A.

Choice A rationale:

Fetal heart tones detected by ultrasound are a positive sign of pregnancy because they provide direct evidence of a fetus.

Choice B rationale:

Breast tenderness is a presumptive sign of pregnancy, not a positive one, as it can be caused by other conditions such as premenstrual syndrome.

Choice C rationale:

A positive urine pregnancy test is a probable sign of pregnancy, not a positive one, as it measures the presence of hCG, a hormone produced during pregnancy. However, certain medications and medical conditions can also produce hCG.

Choice D rationale:

Fatigue is a presumptive sign of pregnancy, not a positive one, as it can be caused by various other conditions such as stress or illness.

The correct answer is choice D.

Choice A rationale:

While antidepressants can be an effective treatment for postpartum depression, it is not the priority action. The priority is to ensure the safety of the mother and the baby.

Choice B rationale:

Reinforcing postpartum and newborn care discharge teaching is important, but it is not the priority action when a client is showing signs of postpartum depression.

Choice C rationale:

Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action when a client is showing signs of postpartum depression.

Choice D rationale:

The priority action when a client is showing signs of postpartum depression is to assess for suicidal ideation or thoughts of harming herself or her baby. This is because postpartum depression can lead to thoughts of self-harm or harm to the baby, and immediate intervention is necessary to ensure the safety of both the mother and the baby.