A nurse is caring for a client who is 39 weeks gestation and having contractions.
Which of the following should the nurse recognize as a sign of true labor?
Uterine contractions that cause variable decelerations.
Regular uterine contractions that cause cervical change.
Station of the presenting part.
Rupture of the membranes resulting in uterine contractions.
The Correct Answer is B
Choice A rationale
Uterine contractions that cause variable decelerations are not specific to true labor. Variable decelerations are typically associated with umbilical cord compression and can occur during both true and false labor.
Choice B rationale
Regular uterine contractions that cause cervical change are a definitive sign of true labor. True labor is characterized by contractions that become progressively stronger, more frequent, and more regular, leading to cervical dilation and effacement. This process indicates that the body is preparing for childbirth.
Choice C rationale
The station of the presenting part refers to the position of the fetus in relation to the ischial spines of the pelvis. While it is an important aspect of labor progression, it is not a definitive sign of true labor.
Choice D rationale
Rupture of the membranes, or the breaking of the water, can occur before true labor begins. While it often indicates that labor is imminent, it is not a definitive sign of true labor on its own.
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Correct Answer is B
Explanation
Choice A rationale
Early decelerations are characterized by a gradual decrease and return to baseline of the fetal heart rate that coincides with the peak of a contraction. They are typically benign and related to fetal head compression.
Choice B rationale
Late decelerations are characterized by a gradual decrease and return to baseline of the fetal heart rate that occurs after the peak of a contraction. They are associated with uteroplacental insufficiency and require prompt intervention to improve fetal oxygenation.
Choice C rationale
Variable decelerations are characterized by an abrupt decrease in fetal heart rate that varies in duration, intensity, and timing relative to contractions. They are often caused by umbilical cord compression and may require interventions to relieve the compression.
Choice D rationale
Prolonged decelerations are characterized by a decrease in fetal heart rate that lasts longer than 2 minutes but less than 10 minutes. They indicate a more severe and sustained disruption in fetal oxygenation and require immediate intervention.
Correct Answer is A
Explanation
Choice A rationale
Breech presentation means the fetus’s buttocks or feet are positioned to be delivered first. Fetal heart tones are often heard above the umbilicus in this position.
Choice B rationale
Transverse lie means the fetus is lying horizontally in the uterus. Fetal heart tones would typically be heard at the sides of the abdomen.
Choice C rationale
Cephalic presentation means the fetus’s head is positioned to be delivered first. Fetal heart tones are usually heard below the umbilicus in this position.
Choice D rationale
Oblique lie means the fetus is positioned diagonally in the uterus. Fetal heart tones can be variable depending on the exact position.