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The nurse is trying to differentiate true labor from false labor. Which of the following is correct regarding true labor?
- A. Discomfort of the contraction is in the fundus.
- B. Contractions do not follow a pattern.
- C. Contractions get stronger with ambulation.
- D. Contractions may stop with ambulation.
Correct Answer: C
Rationale: Contractions get stronger with ambulation in true labor. True labor is also marked by the onset of regular, rhythmic contractions.
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A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor?
- A. There is no dilation.
- B. The contractions are in the fundus.
- C. The cervix has softened and effaced.
- D. The contractions are irregular.
Correct Answer: C
Rationale: One sign of true labor is when the cervix has softened and effaced. True labor contractions are regular and rhythmic.
Which assessment findings suggest probable fetal distress?
- A. Fetal heart rate (FHR) of 120
- B. Meconium-stained amniotic fluid
- C. Decreased FHR during contractions
- D. Strong contractions 10 seconds apart
- E. Slow return of FHR to baseline
Correct Answer: B,E
Rationale: Meconium-stained amniotic fluid and the slow return of the FHR to the baseline are indicative of fetal distress. All other options are normal.
During the second stage of labor how often should the nurse monitor the fetal heart rate?
- A. Every 5 minutes
- B. Every 15 minutes
- C. Every 30 minutes
- D. Every hour
Correct Answer: A
Rationale: Fetal heart rate should be assessed every 5 minutes during the second stage of labor.
A nurse shows the patient an x-ray of the fetal spine in parallel alignment with the mother's to demonstrate a ___ lie.
Correct Answer: longitudinal
Rationale: A longitudinal lie is when the fetal spine and the maternal spine are parallel to each other.
How do Braxton-Hicks contractions differ from labor contractions?
- A. Last several minutes.
- B. Are always regular.
- C. Do not dilate the cervix.
- D. Are only mild.
Correct Answer: C
Rationale: Braxton-Hicks contractions do not dilate the cervix. Braxton-Hicks contractions remain irregular, can range from mild to moderate in severity, and increase in duration as the pregnancy progresses.