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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. Cervical dilation
- B. Report of pain above the umbilicus
- C. Brownish vaginal discharge
- D. Amniotic fluid in the vaginal vault
Correct Answer: A
Rationale: Cervical dilation is a key physiological change that confirms labor has begun. During the late stages of pregnancy, the cervix starts to soften, thin out (efface), and open up (dilate) in preparation for childbirth. Therefore, cervical dilation is a critical finding that indicates the onset of labor. Pain above the umbilicus, brownish vaginal discharge, and amniotic fluid in the vaginal vault are not definitive signs of labor and do not confirm the initiation of the labor process.
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The nurse is assessing a client diagnosed with placenta previa. Which findings should the nurse expect to note?
- A. Uterine rigidity.
- B. Severe abdominal pain.
- C. Bright red vaginal bleeding.
- D. Soft, relaxed, nontender uterus.
Correct Answer: C
Rationale: Placenta previa presents as painless bright red bleeding and a soft, non-tender uterus.
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 min
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate
- D. variability Fetal heart rate of 118/min
Correct Answer: B
Rationale: Prolonged contractions lasting more than 90-120 seconds may reduce placental perfusion and oxygenation to the fetus, leading to fetal distress. This can result in fetal hypoxia and compromise. Therefore, if the contraction duration reaches 100 seconds, it is an indication for the nurse to discontinue the oxytocin infusion to prevent harm to the fetus. Monitoring for appropriate contraction duration is crucial to ensure the well-being of both the mother and the fetus during labor. While contraction frequency every 3 minutes, a fetal heart rate with moderate variability, and a fetal heart rate of 118/min can be normal findings during labor, a prolonged contraction duration is a concerning sign that requires immediate intervention.
A client at 34 weeks' gestation reports regular uterine contractions. What is the nurse's priority action?
- A. Encourage ambulation to relieve discomfort.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Administer an analgesic as prescribed.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction pattern is crucial to evaluate for preterm labor.
The nurse is assessing a client at 20 weeks' gestation who reports leg cramps. What is the most likely cause?
- A. Dehydration.
- B. Calcium deficiency.
- C. Increased blood volume.
- D. Compression of pelvic nerves.
Correct Answer: D
Rationale: Compression of pelvic nerves from the growing uterus can cause leg cramps during pregnancy.
Which complication of adolescent pregnancy should the nurse plan to monitor?
- A. Anemia
- B. Placenta previa
- C. Abruptio placenta
- D. Incompetent cervix
Correct Answer: D
Rationale: Incompetent cervix, also known as cervical insufficiency, is a condition where the cervix begins to dilate and efface prematurely due to weak cervical tissue. This can lead to late miscarriage or preterm birth. Adolescent mothers are at a higher risk for this complication due to their immature reproductive systems. Therefore, the nurse should plan to monitor for signs and symptoms of incompetent cervix in adolescent pregnant clients to prevent adverse maternal and fetal outcomes. Anemia, placenta previa, and abruptio placenta are other potential complications of pregnancy, but they are not specifically associated with adolescent pregnancy.