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?
"Report of pain above the umbilicus"
"Amniotic fluid in the vaginal vault"
"Brownish vaginal discharge"
"Cervical dilation"
The Correct Answer is D
Choice A: Pain above the umbilicus may be associated with various conditions during pregnancy, but it is not a definitive sign of labor.
Choice B: The presence of amniotic fluid in the vaginal vault (rupture of membranes or "water breaking") can be a sign of labor, but it is not the most specific indicator.
Choice C: Brownish vaginal discharge may indicate the passage of old blood or "bloody show," which can be a sign of impending labor. However, it is not as reliable as cervical dilation.
Choice D: Cervical dilation is one of the most definitive signs of labor. As the cervix opens and thins (effaces), it allows for the baby's passage through the birth canal. Cervical dilation is an essential indicator of active labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Administering a 500 mL bolus of 5% dextrose in water is not necessary before the epidural administration, and it may not be recommended in active labor as it can increase the risk of fluid overload.
B: The duration of the anesthetic effect of the epidural can vary depending on the medication used, and it is not the nurse's priority during the preparation process.
C: Prior to administering epidural analgesia, the nurse should obtain a 30minute electronic fetal monitoring (EFM) strip to assess the fetal heart rate and monitor for any signs of fetal distress during the procedure.
D: Having the client stand very still with her arms at her side is not practical or necessary for epidural administration and could be uncomfortable for the client during labor.
Correct Answer is C
Explanation
A) Fetal head compression: Fetal head compression would typically result in variable decelerations, not late decelerations.
B) Umbilical cord compression: Umbilical cord compression is associated with variable decelerations, not late decelerations.
C) Uteroplacental insufficiency: Late decelerations occur due to decreased blood flow and oxygen supply to the fetus, which can be caused by uteroplacental insufficiency. This condition can lead to fetal hypoxia during contractions.
D) Maternal bradycardia: Maternal bradycardia would not directly cause late decelerations in the fetal heart rate.
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