Aureissisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirms that the client is in labor?
Fain just above the navel
Cervical dilation
Amniotic fluid in the vaginal vault
Contractions every 3 to 4 min
The Correct Answer is B
Choice A rationale: Pain above the navel is not a specific indicator of labor and may be unrelated to the onset of labor.
Choice B rationale: Cervical dilation is a definitive sign of labor. It indicates that the cervix is opening to allow the baby's passage through the birth canal.
Choice C rationale: The presence of amniotic fluid in the vaginal vault (rupture of membranes) could indicate that the client's water has broken, but it does not confirm active labor. Labor can begin before or after the rupture of membranes.
Choice D rationale: Regular contractions are a typical sign of labor, but their frequency alone does not confirm active labor. Other signs, such as cervical dilation and effacement, are necessary to confirm active labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Increasing the intake of iron is important during pregnancy to prevent anemia, but it is not specifically related to reducing the risk of neural tube defects.
Choice B rationale: Avoiding the consumption of alcohol during pregnancy is essential to prevent fetal alcohol syndrome, but it is not directly related to reducing the risk of neural tube defects.
Choice C rationale: Avoiding the use of aspirin during pregnancy is recommended to reduce the risk of certain complications, but it is not specifically related to reducing the risk of neural tube defects.
Choice D rationale: Eating foods fortified with folic acid is a crucial preventive measure to reduce the risk of neural tube defects. Adequate folic acid intake before and during early pregnancy significantly lowers the risk of these birth defects.
Correct Answer is A
Explanation
Choice A rationale: The Moro reflex, also known as the startle reflex, is elicited by making a loud noise or performing a sharp hand clap near the newborn. In response to the stimulus, the newborn will throw their arms and legs outward and then bring them back toward the center of the body.
Choice B rationale: Placing a finger at the base of the newborn's toes is not related to eliciting the Moro reflex. This action may elicit the Babinski reflex, which causes the toes to fan out and the big toe to dorsiflex.
Choice C rationale: This action may elicit the stepping reflex, where the newborn will make stepping movements when the soles of their feet touch a flat surface. It is not related to eliciting the Moro reflex.
Choice D rationale: Turning the newborn's head quickly to one side is not related to eliciting the Moro reflex. This action may elicit the asymmetric tonic neck reflex (ATNR), where the newborn will extend the arm and leg on the side their head is turned to and flex the opposite arm and leg.
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