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NurseDive Free Nursing Practice Question
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?
A. "Report of pain above the umbilicus"
Pain above the umbilicus may be associated with various conditions during pregnancy, but it is not a definitive sign of labor.
B. "Amniotic fluid in the vaginal vault"
The presence of amniotic fluid in the vaginal vault (rupture of membranes or "water breaking") can be a sign of labor, but it is not the most specific indicator.
C. "Brownish vaginal discharge"
Brownish vaginal discharge may indicate the passage of old blood or "bloody show," which can be a sign of impending labor. However, it is not as reliable as cervical dilation.
D. "Cervical dilation"
Cervical dilation is one of the most definitive signs of labor. As the cervix opens and thins (effaces), it allows for the baby's passage through the birth canal. Cervical dilation is an essential indicator of active labor.
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Full Explanation
Choice A: Pain above the umbilicus may be associated with various conditions during pregnancy, but it is not a definitive sign of labor.
Choice B: The presence of amniotic fluid in the vaginal vault (rupture of membranes or "water breaking") can be a sign of labor, but it is not the most specific indicator.
Choice C: Brownish vaginal discharge may indicate the passage of old blood or "bloody show," which can be a sign of impending labor. However, it is not as reliable as cervical dilation.
Choice D: Cervical dilation is one of the most definitive signs of labor. As the cervix opens and thins (effaces), it allows for the baby's passage through the birth canal. Cervical dilation is an essential indicator of active labor.
Similar Questions
A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?
A. Insert an indwelling urinary catheter to maintain an empty blaadder at all times.
Choice A: Insert an indwelling urinary catheter to maintain an empty bladder at all times. Routinely inserting an indwelling urinary catheter is not necessary for maintaining an empty bladder during labor. While it is important to ensure the client has a voiding schedule, the use of an indwelling catheter should be reserved for specific medical indications, such as when the client is unable to void or has received an epidural. Indwelling catheters can increase the risk of catheter-associated urinary tract infections (CAUTIs) and should be used judiciously.
B. Keep four side rails up while the client is in bed, maintaining strict bedrest.
Choice B: Keep four side rails up while the client is in bed, maintaining strict bedrest. Keeping all four side rails up and maintaining strict bedrest is not appropriate during active labor. This practice can limit the client’s movement, which is essential for comfort and progress during labor. Movement and changing positions can help labor progress and reduce pain. Strict bedrest is generally reserved for specific medical conditions, such as preterm labor or other complications.
C. Monitor the fetal heart rate (FHR) hourly during active labor.
Choice C: Monitor the fetal heart rate (FHR) hourly during active labor. Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus. However, hourly monitoring may not be sufficient. Guidelines recommend more frequent monitoring, typically every 15-30 minutes during the active phase of labor and every 5-15 minutes during the second stage. Continuous electronic fetal monitoring may be used for high-risk pregnancies or if there are signs of fetal distress.
D. Check the cervix to determine how close the time of delivery may be prior to analgesic administration.
Choice D: Check the cervix to determine how close the time of delivery may be prior to analgesic administration. Checking the cervix to determine how close the time of delivery may be prior to analgesic administration is important. This practice helps ensure that analgesics are administered at an appropriate time, avoiding potential complications such as delayed delivery or inadequate pain relief. Cervical checks provide valuable information about the progress of labor and help guide clinical decisions regarding pain management and delivery planning.
Full Explanation
Choice A: Insert an indwelling urinary catheter to maintain an empty bladder at all times.
Routinely inserting an indwelling urinary catheter is not necessary for maintaining an empty bladder during labor. While it is important to ensure the client has a voiding schedule, the use of an indwelling catheter should be reserved for specific medical indications, such as when the client is unable to void or has received an epidural. Indwelling catheters can increase the risk of catheter-associated urinary tract infections (CAUTIs) and should be used judiciously.
Choice B: Keep four side rails up while the client is in bed, maintaining strict bedrest.
Keeping all four side rails up and maintaining strict bedrest is not appropriate during active labor. This practice can limit the client’s movement, which is essential for comfort and progress during labor. Movement and changing positions can help labor progress and reduce pain. Strict bedrest is generally reserved for specific medical conditions, such as preterm labor or other complications.
Choice C: Monitor the fetal heart rate (FHR) hourly during active labor.
Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus. However, hourly monitoring may not be sufficient. Guidelines recommend more frequent monitoring, typically every 15-30 minutes during the active phase of labor and every 5-15 minutes during the second stage. Continuous electronic fetal monitoring may be used for high-risk pregnancies or if there are signs of fetal distress.
Choice D: Check the cervix to determine how close the time of delivery may be prior to analgesic administration.
Checking the cervix to determine how close the time of delivery may be prior to analgesic administration is important. This practice helps ensure that analgesics are administered at an appropriate time, avoiding potential complications such as delayed delivery or inadequate pain relief. Cervical checks provide valuable information about the progress of labor and help guide clinical decisions regarding pain management and delivery planning.
A nurse is caring for a client who is a primigravida, at term, and having contractions. The client states that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as the most reliable sign of true labor?
A. Engagement of the presenting part
Engagement of the presenting part occurs when the baby's head descends into the pelvis. While it is a sign of labor progression, it can also happen weeks before labor begins.
B. Progressive changes in the effacement and dilation of the cervix
Progressive changes in the effacement (thinning) and dilation (opening) of the cervix are the most reliable signs of true labor. As the cervix changes, it indicates that labor is actively occurring.
C. Rupture of the membranes
Rupture of the membranes (water breaking) is another sign of labor, but it can happen before or during labor. It may not be the most reliable sign by itself.
D. Irregular pattern of contractions
Regular and frequent contractions are essential for labor to progress, but an irregular pattern of contractions may still be associated with false labor or early labor.
Full Explanation
Choice A: Engagement of the presenting part occurs when the baby's head descends into the pelvis. While it is a sign of labor progression, it can also happen weeks before labor begins.
Choice B: Progressive changes in the effacement (thinning) and dilation (opening) of the cervix are the most reliable signs of true labor. As the cervix changes, it indicates that labor is actively occurring.
Choice C: Rupture of the membranes (water breaking) is another sign of labor, but it can happen before or during labor. It may not be the most reliable sign by itself.
Choice D: Regular and frequent contractions are essential for labor to progress, but an irregular pattern of contractions may still be associated with false labor or early labor.
A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?
A. "A repeat cesarean birth will always be safer for both you and your baby."
It is not accurate to say that a repeat cesarean birth will always be safer. The decision for a repeat cesarean or a trial of labor after cesarean (TOLAC) depends on various factors, including the client's medical history and the type of incision used in the previous cesarean.
B. "There are so many variables to consider that you will have to ask your obstetrician about this."
While there are multiple factors to consider, the nurse can still provide general information about the possibility of attempting a vaginal birth after cesarean (VBAC).
C. "It's too soon for you to be worrying about your next pregnancy and birth. Focus on your healthy baby."
While focusing on the health of the newborn is important, the client's question about the possibility of a future VBAC can be addressed without dismissing her concerns.
D. "The type of incision performed with this birth will determine if you can attempt a VBAC in the future."
The type of incision used in the previous cesarean birth (such as low transverse incision) is a significant factor in determining the eligibility for a VBAC in subsequent pregnancies. Clients with certain types of incisions may have a higher likelihood of success with a VBAC.
Full Explanation
Choice A: It is not accurate to say that a repeat cesarean birth will always be safer. The decision for a repeat cesarean or a trial of labor after cesarean (TOLAC) depends on various factors, including the client's medical history and the type of incision used in the previous cesarean.
Choice B: While there are multiple factors to consider, the nurse can still provide general information about the possibility of attempting a vaginal birth after cesarean (VBAC).
Choice C: While focusing on the health of the newborn is important, the client's question about the possibility of a future VBAC can be addressed without dismissing her concerns.
Choice D: The type of incision used in the previous cesarean birth (such as low transverse incision) is a significant factor in determining the eligibility for a VBAC in subsequent pregnancies. Clients with certain types of incisions may have a higher likelihood of success with a VBAC.