A woman at 40 weeks gestation calls the labor unit to see whether or not she should go to the hospital to be evaluated.
Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital?
The contractions are 5 to 20 minutes apart.
The contractions are regular, about a minute long and I am unable to talk through them.
I saw a pink discharge on the toilet tissue when I went to the bathroom.
I have had cramping for the past 4 hours.
The Correct Answer is B
Choice A rationale
Contractions spaced 5 to 20 minutes apart can indicate early labor, but regular and intense contractions closer together suggest active labor. This does not indicate imminent hospital visit.
Choice B rationale
Regular contractions lasting about a minute and causing inability to talk through them are strong indicators of active labor, suggesting the need for hospital evaluation.
Choice C rationale
Seeing a pink discharge (bloody show) indicates the cervix is starting to dilate but does not necessarily mean active labor is present. It's not the most immediate sign to proceed to hospital.
Choice D rationale
Cramping for 4 hours can be a sign of early labor, but it lacks the regularity and intensity of active labor contractions. This does not suggest an immediate need for hospital visit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Drinking as much as desired, even in the second trimester, can lead to fetal alcohol spectrum disorders. No safe amount of alcohol is known during pregnancy.
Choice B rationale
Despite being in the second trimester, no level of alcohol consumption is considered safe during pregnancy, as it poses a risk to fetal development.
Choice C rationale
The safest course is to abstain from alcohol throughout pregnancy as no specific amount has been deemed safe and it can cause irreversible harm to fetal development.
Choice D rationale
Even limiting alcohol consumption to three times a week poses a risk to fetal health, as any amount can potentially cause developmental issues.
Correct Answer is B
Explanation
Choice A rationale
Hypertension is not a common side effect of epidural blocks; instead, hypotension is more likely due to vasodilation. Monitoring for hypertension is not the most important intervention.
Choice B rationale
Bradycardia is a potential side effect of epidural blocks due to sympathetic blockade. Monitoring the maternal pulse for bradycardia ensures timely intervention if this side effect occurs.
Choice C rationale
Epidural blocks do not typically cause fetal tachycardia. Monitoring the fetus for tachycardia is not the primary nursing intervention following epidural administration.
Choice D rationale
Limiting parenteral fluids is not advised after an epidural block as fluids are essential to counteract potential hypotension. Fluid management is crucial to maintain maternal and fetal hemodynamics.
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