A primigravida at 40 weeks of gestation is having erratic uterine contractions every 5 to 10 minutes and states that they are very painful.
Her cervix is dilated 2 cm and has not changed in 3 hours.
The woman is crying and wants an epidural.
What is the likely status of this woman's labor?
She is exhibiting hypotonic uterine dysfunction.
She is experiencing a normal latent stage.
She is exhibiting hypertonic uterine dysfunction.
She is experiencing precipitous labor.
The Correct Answer is B
Choice A rationale
Hypotonic uterine dysfunction typically occurs in the active phase of labor (after 4 cm cervical dilation) and is characterized by weak, infrequent, and ineffective contractions that do not lead to cervical change. The client in the latent phase with slow cervical change is not yet in the active phase.
Choice B rationale
The latent phase of the first stage of labor is characterized by irregular, mild to moderate contractions that cause slow, gradual cervical dilation and effacement. It can be lengthy, especially in primigravidas, and the discomfort can be significant. A cervical dilation of 2 cm with no change in 3 hours in the presence of painful, erratic contractions every 5 to 10 minutes aligns with a normal latent phase.
Choice C rationale
Hypertonic uterine dysfunction usually occurs in the latent phase and is characterized by frequent, uncoordinated, and strong contractions that are ineffective in causing cervical dilation or effacement. While the contractions are painful, they are not described as excessively strong or uncoordinated, and the client is in the expected early stage of labor.
Choice D rationale
Precipitous labor is a very rapid labor and delivery, typically lasting less than 3 hours from the onset of regular contractions to expulsion of the fetus. The client's labor is progressing slowly, with minimal cervical change over 3 hours, which is the opposite of precipitous labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Supine positioning can compress the vena cava, leading to decreased venous return, reduced cardiac output, and potential maternal hypotension, which can compromise fetal oxygenation. Alternative positions like lateral or semi-recumbent are generally preferred during labor to optimize blood flow.
Choice B rationale
Assessing anesthesia or pain level every 30 minutes is crucial in the active phase of labor to evaluate the effectiveness of pain management interventions and the client's comfort. This frequent monitoring allows for timely adjustments to the pain management plan based on the client's subjective experience and physiological responses.
Choice C rationale
While assessing vaginal bleeding and the fundus is important in the postpartum period to monitor for uterine involution and hemorrhage, it is not the priority during the active phase of labor. The focus during active labor is on maternal and fetal well-being during the labor process itself.
Choice D rationale
Continuous or intermittent oxygen saturation monitoring may be indicated based on the client's condition and fetal heart rate patterns, but it is not a routine assessment every half hour for all clients in active labor. It is typically reserved for situations of suspected maternal hypoxemia or fetal distress.
Correct Answer is A
Explanation
Choice A rationale
True labor is characterized by progressive cervical changes, including effacement (thinning) and dilation (opening) of the cervix. These changes are the most definitive signs that a woman is in true labor, as contractions can sometimes be Braxton Hicks contractions, which do not cause cervical change.
Choice B rationale
The station of the presenting part (how far down the baby's head is in the pelvis) can change during true labor as the baby descends. However, a single assessment of station does not definitively indicate true labor, as the baby may have been in a lower position prior to the onset of labor. Cervical changes are a more reliable indicator.
Choice C rationale
Rupture of the membranes (water breaking) can occur before or during true labor, but it is not always the first sign of labor. Some women experience contractions for a period before their membranes rupture, and some may not have their membranes rupture until late in labor or require artificial rupture. Therefore, it is not the most definitive sign of true labor.
Choice D rationale
A pattern of regular contractions that increase in frequency, duration, and intensity is a strong indication of true labor. However, some women may experience irregular contractions (Braxton Hicks) that can be mistaken for early labor. The key differentiator is whether these contractions are causing cervical change, making cervical assessment the most definitive sign.
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