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 A
Explanation
Choice A rationale
Monitoring the fetal heart rate is the next appropriate action. The fetal heart rate provides crucial information about the fetus’s well-being and can help identify any potential issues that may need further intervention.
Choice B rationale
Monitoring uterine contractions is important, but in this scenario, the client’s vital signs are stable, and there is no indication of labor. Therefore, monitoring the fetal heart rate takes precedence.
Choice C rationale
Amniotic fluid levels are important to monitor, but they are typically assessed through ultrasound rather than immediate bedside monitoring. The fetal heart rate provides more immediate information about the fetus’s condition.
Choice D rationale
Cervical dilation is relevant during labor, but there is no indication that the client is in labor based on the provided vital signs. Monitoring the fetal heart rate is more pertinent in this situation.
Correct Answer is B
Explanation
Choice A rationale
Providing ice chips or mouth swabs can help keep the client comfortable and hydrated, but it is not the priority action when administering pain medication.
Choice B rationale
Assessing and documenting maternal vital signs and fetal heart rate after administering Fentanyl is crucial. This ensures that the medication is not causing any adverse effects on the mother or fetus and that both are stable.
Choice C rationale
Dimming the lights and providing a quiet atmosphere can help create a calming environment, but it is not the priority action when administering pain medication.
Choice D rationale
Assisting the patient with coping skills, including breathing techniques, is important for managing pain, but it is not the priority action when administering pain medication.