Nokea
The nurse is caring for the pregnant client. Which assessment findings help the nurse determine that she may be in true labor? Select all that apply.
- A. Progressive cervical dilation and effacement
- B. Walking usually increases contraction intensity
- C. Warm tub baths and rest lessen contractions
- D. Discomfort is usually in the client’s abdomen
- E. Contractions increase in duration and intensity
Correct Answer: A,B,E
Rationale: Progressive cervical dilation and effacement indicate true labor. In false labor, the contractions may occur for several hours, but there is no cervical change. In true labor, walking usually increases the intensity of contractions. In false labor, walking usually has little or no effect on contractions and may sometimes decrease the frequency, intensity, and duration of contractions. Contractions increase in duration and intensity during true labor, while there is usually no change in contractions during false labor. Warm tub baths and rest lessen contractions during false labor. In true labor, contractions do not decrease with warm tub baths or rest. Discomfort is usually in the client’s abdomen during false labor. Discomfort begins in the back and radiates around to the abdomen during true labor.
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The nurse correctly explains that the bleeding is the result of sloughing of which structure?
- A. Endometrium
- B. Myometrium
- C. Epimetrium
- D. None of the above
Correct Answer: A
Rationale: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.
The nurse advises the client to practice which technique to cope with labor pain?
- A. Lamaze breathing
- B. Holding her breath
- C. Tensing muscles
- D. Avoiding movement
Correct Answer: A
Rationale: Lamaze breathing helps manage labor pain by promoting relaxation and focus, unlike tensing or breath-holding.
The 42-year-old client who had a partial hydatidiform molar pregnancy 3 months ago asks the nurse whether she and her husband can try conceiving again. Which response by the nurse is incorrect and warrants follow-up action by the observing nurse manager?
- A. “You will need serial levels of beta human chorionic gonadotropin (BHCG) drawn.”
- B. “You cannot conceive ever again because of your risk of choriocarcinoma.”
- C. “You should not become pregnant yet for 6 to 12 months.”
- D. “Your risk of another hydatidiform molar pregnancy is low.”
Correct Answer: B
Rationale: Women who have had a molar pregnancy can conceive again once their BHCG levels are normal and remain normal for a certain time period, usually 6 to 12 months. This response by the nurse is incorrect and should be followed up by the observing nurse manager. Because of the risk of choriocarcinoma, serial serum BHCG testing is completed after a hydatidiform molar pregnancy. Because the client will undergo serial serum BHCG testing after a hydatidiform molar pregnancy, she should not get pregnant for 6 to 12 months until testing is completed and it is confirmed that she does not have a malignancy. Couples with a past history of molar pregnancy have the same statistical chance of conceiving again and having a normal pregnancy as those without.
The nurse correctly instructs the client to contact the physician immediately under which circumstance?
- A. When the first fetal movement is felt
- B. If the breasts become tender
- C. If vaginal bleeding occurs
- D. When experiencing frequent urination
Correct Answer: C
Rationale: Vaginal bleeding is a danger sign in pregnancy, potentially indicating miscarriage or placental issues, requiring immediate reporting.
The laboring client presents with ruptured membranes, frequent contractions, and bloody show. She reports a greenish discharge for 2 days. Place the nurse’s actions in the order that they should be completed.
- A. Perform a sterile vaginal exam
- B. Assess the client thoroughly
- C. Obtain fetal heart tones
- D. Notify the health care provider
Correct Answer: C,A,B,D
Rationale: Obtain FHT should be first. The client has ruptured membranes with greenish fluid, and the fetus could be experiencing nonreassuring fetal status. Perform a sterile vaginal exam to determine labor progression. Assess the client thoroughly. This needs to be completed prior to notifying the HCP with the information. Notify the HCP is last of the options. Assessment findings would need to be reported to the HCP. The client should then be moved into an inpatient room.