A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not.”. Which of the following is the BEST indicator of true labor that the nurse should recognize?
Premature rupture of the membranes.
Light irregular pattern of contractions.
3 station of the presenting part.
Progressive cervical dilation.
The Correct Answer is D
Choice A rationale
Premature rupture of the membranes refers to the breaking of the amniotic sac before labor starts. It is not a definitive indicator of true labor, as contractions and cervical changes need to accompany it to confirm labor onset.
Choice B rationale
Light irregular pattern of contractions is often associated with false labor or Braxton Hicks contractions. True labor contractions are typically regular, progressively stronger, and closer together.
Choice C rationale
3 station of the presenting part refers to the baby's descent into the pelvis. While it indicates labor progression, it is not the most definitive sign of true labor compared to cervical changes.
Choice D rationale
Progressive cervical dilation is the most reliable indicator of true labor. It signifies that the cervix is opening up in response to regular and effective contractions, indicating the body is preparing for childbirth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale for correct condition: The client is likely experiencing PPROM, as evidenced by the sudden gush of clear fluid and continued light leakage, confirmed by fluid pooling in the vaginal vault that tested positive for ferning. PPROM can lead to preterm labor and increased risk of infection. The absence of contractions or bleeding, and the mild lower abdominal discomfort, further supports this diagnosis.
Rationale for actions: Administering prophylactic antibiotics helps prevent infection, which is a significant risk with PPROM. Educating the client on kick counts ensures monitoring of fetal well-being. Preparing for an emergent C-section is not immediately necessary as the cervix is closed. Providing IV fluids for hypotension is not applicable here as blood pressure is elevated. Discharging the client with follow-up in one week is inappropriate given the risk of infection and preterm labor.
Rationale for parameters: Monitoring signs of infection is crucial, as PPROM increases infection risk. Maternal blood pressure trends must be watched due to elevated readings, suggesting possible complications. Meconium-stained amniotic fluid, while concerning, is not present. Maternal platelet levels and fundal height measurements do not directly address the current risks associated with PPROM.
Rationale for incorrect conditions: Placental abruption typically involves abdominal pain and bleeding, which are absent. Preeclampsia involves hypertension and proteinuria, but no significant proteinuria is present. Oligohydramnios involves decreased amniotic fluid, but the client reports clear fluid leakage indicating rupture of membranes.
Correct Answer is ["7"]
Explanation
Step 1 is 2800 grams × 2.5 mg/kg. 2800 grams × 2.5 mg/kg = 7000 mg/kg.
Step 2 is 7000 mg ÷ (1000 mg/kg). 7000 mg ÷ (1000 mg/kg) = 7 mg.
Final calculated answer: 7 mg.
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