At midpoint during pregnancy, you review beginning signs of labor with a client. One of the beginning signs of labor you would review is:
sharp, right-sided abdominal pain.
a sudden gush of clear fluid from the vagina
an increased pulse rate and upper abdominal pain
excessive fatigue and headache.
The Correct Answer is B
B. A sudden gush of clear fluid from the vagina, especially if it continues to leak, is a classic sign that the amniotic sac has ruptured, known as the rupture of membranes or "water breaking." This can occur as a sign of early labor, although it does not always mean active labor has begun. It is important for the client to notify their healthcare provider if this occurs.
A. Sharp, right-sided abdominal pain is not typically associated with the beginning signs of labor. It could indicate other conditions such as appendicitis or gallbladder issues, which would require medical evaluation. Therefore, this option is not correct in the context of signs of labor.
C. An increased pulse rate and upper abdominal pain can be signs of certain complications during pregnancy but they are not typical signs of the onset of labor itself. These symptoms could indicate conditions such as preeclampsia or other medical issues that need prompt evaluation by a healthcare provider.
D. Excessive fatigue and headache can occur during pregnancy due to hormonal changes, increased physical demands, or other factors. However, they are not specific signs of the onset of labor. These symptoms should be discussed with a healthcare provider to determine their cause and appropriate management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. This is crucial because the procedure can lead to changes in the fetal heart rate, indicating fetal distress or well-being. Monitoring the fetal heart rate helps ensure that the fetus is tolerating the procedure well and allows for prompt intervention if any issues arise.
A. This is an important action after amniotomy to assess for meconium-stained amniotic fluid, which could indicate fetal distress. However, it is not the immediate priority.
B. Chills and increased uterine tenderness can indicate infection (chorioamnionitis) following amniotomy, which is a potential complication. Prompt identification and treatment of infection are crucial to prevent maternal and fetal complications. However, this is not the immediate priority.
D. Monitoring the client's temperature is essential in detecting early signs of infection, such as fever, which can occur post-amniotomy. Fever is a significant indicator of chorioamnionitis and requires immediate intervention. However, it is not the immediate priority
Correct Answer is C
Explanation
C. Monitoring respiratory rate is important because magnesium sulfate can depress respiratory function, especially if given in high doses or if the client has impaired renal function.
A. While assessing bowel sounds is important in general nursing care, it is not the priority assessment when administering magnesium sulfate.
B. Monitoring the fetal heart rate is critical when administering magnesium sulfate to a client in preterm labor. Magnesium sulfate can cross the placenta and affect the fetal heart rate and variability. However, respiratory rate is priority.
D. Monitoring temperature is important as magnesium sulfate can affect thermoregulation, potentially causing hyperthermia. However, it is not typically the most immediate concern compared to fetal heart rate monitoring when initiating magnesium sulfate therapy.
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