What should the nurse emphasize as being characteristic of false labor contractions?
They do not result in cervical change.
They will increase in intensity and strength.
They do not increase in frequency and intensity.
They often disappear with rest or sleep.
They are irregular.
Correct Answer : A,D,E
Choice A rationale
False labor contractions, also known as Braxton Hicks contractions, are uncoordinated and do not cause effacement or dilation of the cervix. They are considered practice contractions. True labor contractions, in contrast, cause progressive cervical changes, which is the definitive sign of true labor. This is the key physiological difference between true and false labor.
Choice B rationale
This statement describes true labor contractions, not false labor. True labor contractions will increase in intensity, duration, and frequency over time. As the labor progresses, the contractions become stronger and more powerful, leading to cervical changes. False labor contractions are typically inconsistent in their strength and may even weaken over time.
Choice C rationale
This statement is an incomplete description of false labor. While they do not necessarily increase in frequency and intensity, a key characteristic is that they are irregular in their pattern. True labor contractions, on the other hand, are regular and follow a predictable pattern of increasing frequency and intensity.
Choice D rationale
False labor contractions often diminish or disappear with rest, changes in activity, or hydration. This is a common characteristic that helps to distinguish them from true labor. True labor contractions will continue regardless of rest, sleep, or changes in activity and will often become stronger with ambulation.
Choice E rationale
False labor contractions are typically irregular in their timing and duration. The interval between contractions does not shorten, and the intensity does not increase. True labor contractions, however, are regular and predictable, following a pattern of increasing frequency, duration, and intensity as labor progresses. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Ambulation is the most effective intervention for preventing thromboembolism. Movement of the lower extremities promotes venous return and blood flow, preventing venous stasis, which is the primary predisposing factor for clot formation. Encouraging the client to get out of bed and walk as soon as medically stable after a cesarean birth reduces the risk of deep vein thrombosis and subsequent pulmonary embolism by a significant margin.
Choice B rationale
Instructing the client to press inward on their abdomen periodically is not an intervention for thromboembolism prevention. This action may cause discomfort and does not promote blood flow in the lower extremities. It is not a scientifically supported method for preventing venous stasis or clot formation in the legs, which are the main concerns for thromboembolism in this population.
Choice C rationale
Urging the client to cough and take deep breaths is an intervention to prevent respiratory complications like atelectasis and pneumonia. While important for post-operative care, this action does not directly address the risk of thromboembolism in the lower extremities. The mechanism of clot formation is related to venous stasis, which is best addressed by movement and not by respiratory exercises.
Choice D rationale
Urging the client not to dislodge the IV fluid line is an important general safety measure to ensure proper hydration and medication administration. However, it is not an intervention specifically aimed at preventing thromboembolism. The risk of thromboembolism is a circulatory issue related to venous stasis, and this action does not impact blood flow or clot formation in the veins. .
Correct Answer is A
Explanation
A macrosomic infant, weighing over 4000 grams (8 lbs 13 oz), significantly stretches the uterine muscles, leading to a diminished ability to contract effectively after birth. This uterine atony is the primary cause of postpartum hemorrhage. The uterus fails to clamp down on the blood vessels at the placental site, resulting in continuous bleeding. The client’s G6 status further increases this risk due to repeated uterine stretching.
Choice B rationale
Thrombosis is a risk in the postpartum period due to hypercoagulability and venous stasis, but it is not the primary complication associated with a macrosomic infant and high parity. The most immediate and significant risk following this type of delivery is the uterus's inability to contract properly, leading to uncontrolled bleeding. While thrombosis is a concern, it is a secondary risk compared to hemorrhage.
Choice C rationale
Postpartum seizures, also known as eclampsia, are typically associated with preeclampsia and hypertension, not specifically with macrosomic infants or high parity. While a client may have other risk factors for seizures, a large infant and multiparity do not directly cause them. The primary and most immediate physiological risk is the inability of the uterus to involute and stop bleeding.
Choice D rationale
While infection is a risk following any delivery, especially if there are lacerations or a prolonged rupture of membranes, it is not the immediate or most significant complication related to a macrosomic infant. The overwhelming primary concern in this specific scenario is the uterine atony caused by the large infant and multiple pregnancies, which predisposes the client to hemorrhage.
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