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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Related Questions
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.
Correct Answer is A
Explanation
Choice A: The first priority assessment finding to report to the provider is contractions lasting 2 minutes and with no rest between contractions. Prolonged contractions without adequate rest can lead to uterine hyperstimulation and fetal distress, potentially compromising the wellbeing of both the client and the baby. The provider needs to be informed immediately for further
evaluation and intervention.
Choice B: Pressure on the perineum and the desire to bear down indicate that the client is experiencing the urge to push, which is expected during the second stage of labor, not during the active phase of the first stage. It is not the first priority to report.
Choice C: Clear fluid discharge from the vagina can indicate rupture of membranes, but it is not an immediate concern unless the fluid is meconiumstained or there are other signs of fetal distress.
Choice D: Passage of a bloodtinged mucous plug (also known as "bloody show") is a common sign that labor is approaching, but it is not an immediate concern unless there are other signs of labor progression or complications. It is not the first priority to report.
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