The client has been having contractions every 5 minutes for 7 hours.
Which factor would the nurse use to determine if this is true labor?
The cervix is effacing and dilating.
The membranes have ruptured.
This is the client’s second baby.
The contractions are more intense.
The Correct Answer is A
Choice A rationale
Effacement and dilation of the cervix are key indicators of true labor. Effacement refers to the thinning of the cervix, and dilation is the opening. True labor leads to progressive changes in the cervix.
Choice B rationale
Rupture of membranes can occur before, during, or after true labor. While it can be associated with labor, it alone does not confirm true labor as cervical changes do.
Choice C rationale
The number of pregnancies (parity) does not determine true labor. True labor is characterized by progressive cervical changes, not by the client's obstetric history.
Choice D rationale
The intensity of contractions alone does not confirm true labor. True labor is marked by regular, progressively stronger contractions leading to cervical effacement and dilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The tocodynamometer detects both the frequency and intensity of uterine contractions by measuring the pressure changes on the abdomen. It provides real-time data on contraction patterns during labor.
Choice B rationale
Repeating the frequency and intensity of contractions is redundant. The tocodynamometer accurately measures these parameters, providing essential information for managing labor progress.
Choice C rationale
While the tocodynamometer can infer uterine resting tone, it is not designed to measure hypertonus directly. Other methods, like intrauterine pressure catheters, offer more accurate assessments of uterine tone.
Choice D rationale
The tocodynamometer measures the duration of contractions, but it does not solely focus on this parameter. It captures comprehensive data, including frequency and intensity, for effective labor management.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Calling for help and notifying the care provider ensures that expert medical assistance is available promptly for any emergency interventions required.
Choice B rationale
Getting help and preparing the operating room ensures readiness for an immediate cesarean section if fetal distress persists and the situation does not improve rapidly.
Choice C rationale
Starting Pitocin is inappropriate during fetal distress as it may further stress the fetus by increasing contraction frequency and intensity, potentially worsening the situation.
Choice D rationale
Inserting a Foley catheter does not address the immediate concern of fetal distress and would not provide immediate benefit in improving fetal heart rate.
Choice E rationale
Repeating uterine resuscitation measures (e.g., repositioning, oxygen, IV fluids) is essential, but if they are ineffective, additional interventions, such as preparing for possible surgical delivery, are needed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.