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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Posterior neck flexion is not an expected change during pregnancy.
Choice B: Increased abdominal muscle tone is not an expected change during pregnancy. In fact, the abdominal muscles tend to stretch and may become less toned as the uterus expands.
Choice C: During pregnancy, the woman's center of gravity shifts due to the growing uterus, leading to an increased arch in the lower back known as lordosis. This change helps to maintain balance and reduce the strain on the back. The other options are not expected physiologic changes during pregnancy.
Choice D: Decreased mobility of pelvic joints is not an expected change during pregnancy. Some joint laxity may occur due to hormonal changes, but decreased mobility is not typical.
Correct Answer is B
Explanation
A. Maintain the client in the lithotomy position: The lithotomy position is not typically
maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B. Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C. Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D. Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.
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