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 C
Explanation
A. Treat opportunistic infections. Antiretroviral drugs do not directly treat opportunistic infections. They help suppress the HIV virus, which in turn strengthens the immune system, reducing the risk of opportunistic infections, but specific infections require separate antimicrobial treatment.
B. Supplement radiation and chemotherapy. Antiretroviral therapy (ART) is not used as a supplement to radiation or chemotherapy. While HIV-positive patients can develop certain cancers like Kaposi’s sarcoma, ART is aimed at controlling HIV rather than being a direct cancer treatment.
C. Decrease viral loads in the blood. Antiretroviral drugs work by suppressing HIV replication, thereby decreasing viral load in the bloodstream. This helps maintain immune function, reduces the risk of perinatal transmission, and improves overall health outcomes. Consistent use of ART can even lower viral loads to undetectable levels, significantly reducing transmission risk.
D. Cure acute HIV/AIDS infections. There is no cure for HIV/AIDS. Antiretroviral therapy helps manage the disease by reducing viral replication and preventing progression to AIDS, but it does not eradicate the virus from the body. Lifelong adherence to ART is necessary for disease control.
Correct Answer is B
Explanation
A. Fetal heart rate of 118 beats/min. A fetal heart rate of 118 bpm is within the normal range of 110-160 bpm and does not necessarily indicate fetal distress. While continuous monitoring is important in post-term pregnancies, this finding alone does not require urgent assessment.
B. One fetal movement noted in a two-hour assessment by the mother. Decreased fetal movement is a concerning sign that requires further assessment. At 42 weeks gestation, the aging placenta may lead to reduced oxygen and nutrient supply, increasing the risk of fetal compromise. Normally, at least 10 movements should be felt within two hours. A significant decrease in movement could indicate fetal distress or hypoxia, requiring immediate evaluation with a non-stress test (NST) or biophysical profile (BPP).
C. Cervix dilated 2 cm and 50% effaced. A partially dilated and effaced cervix is expected in a post-term pregnancy and does not indicate fetal distress. It suggests that labor may be approaching but does not require additional urgent assessment.
D. Score of 8 on the biophysical profile. A biophysical profile (BPP) score of 8 out of 10 is reassuring and indicates normal fetal well-being. If the score were 4 or lower, it would require immediate intervention, but a score of 8 suggests adequate oxygenation and fetal health.
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