The nurse recognizes that a woman is in true labor when she states…., and finds that her cervix has dilated and effaced on examination.
"My baby dropped, and I have to urinate more frequently now."
The contractions in my uterus are getting stronger and closer together"
I passed some thick pink mucus where I urinated this morning"
"My bag of waters just broke’
The Correct Answer is B
A. Increased urinary frequency and the baby "dropping" indicate lightening, which occurs in the weeks before labor begins. While this is a sign that labor is approaching, it does not confirm true labor.
B. True labor is characterized by contractions that progressively become stronger, closer together, and more regular, leading to cervical dilation and effacement. This distinguishes it from false labor, where contractions are irregular and do not cause cervical changes.
C. Passing thick pink mucus, known as the bloody show, is a sign that labor may begin soon, but it does not confirm that the woman is in active labor. Cervical changes must be assessed to determine true labor.
D. The rupture of membranes, or "water breaking," can occur before or during labor, but it does not necessarily indicate the onset of true labor. Cervical dilation and regular contractions are required to confirm active labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Oligohydramnios. Oligohydramnios, or low amniotic fluid levels, is not a primary complication of pregestational diabetes. It is more commonly associated with conditions such as fetal growth restriction, post-term pregnancy, and rupture of membranes rather than maternal hyperglycemia.
B. Congenital fetal anomalies. Poor glycemic control during preconception and early pregnancy increases the risk of congenital anomalies, particularly affecting the heart, spine, and central nervous system. Hyperglycemia during organogenesis (first 8 weeks of gestation) can lead to defects such as neural tube defects and cardiac malformations.
C. Intrauterine fetal seizures. Fetal seizures in utero are extremely rare and are not a common complication of maternal diabetes. While neonatal hypoglycemia after birth can lead to seizures, maternal hyperglycemia does not directly cause seizures in the fetus.
D. Polyhydramnios. While polyhydramnios (excess amniotic fluid) can occur in pregnancies complicated by diabetes due to fetal polyuria, it is more associated with later pregnancy. The question specifically asks about preconception and early pregnancy risks, making congenital anomalies the best answer.
Correct Answer is B
Explanation
A. Weight gain of 4 pounds in a month. A weight gain of 4 pounds in a month is within the expected range for pregnancy, especially in the third trimester. While rapid or excessive weight gain could indicate fluid retention and worsening heart failure, this amount alone is not immediately concerning.
B. Dyspnea with walking. Dyspnea on exertion in a pregnant woman with congestive heart disease is a serious concern. It may indicate pulmonary congestion, worsening heart failure, or reduced cardiac output. Any increasing shortness of breath, especially with minimal activity, should be reported immediately to prevent complications like pulmonary edema or decompensated heart failure.
C. Presence of striae gravidarum. Striae gravidarum (stretch marks) are a normal skin change in pregnancy due to rapid growth and stretching of the skin. They are not related to congestive heart disease and do not require reporting.
D. Patellar reflexes of +2. A +2 deep tendon reflex (DTR) is normal and does not indicate worsening cardiac status. Reflex abnormalities are more relevant in conditions such as preeclampsia, where hyperreflexia can signal worsening disease, but they are not a concern in heart disease.
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