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 C
Explanation
Choice A rationale
While a negative result in a Contraction Stress Test (CST) is desirable, this choice does not fully explain the significance of the result. A negative CST indicates that there are no late decelerations in the fetal heart rate in response to uterine contractions, suggesting that the fetus can handle the stress of labor.
Choice B rationale
This choice describes the criteria for a reactive Nonstress Test (NST), not a Contraction Stress Test (CST). In a CST, the focus is on the fetal heart rate response to contractions, not the number of contractions or variability.
Choice C rationale
A negative result in a CST indicates fetal well-being, meaning that the fetus can tolerate the stress of uterine contractions without showing signs of distress, such as late decelerations in the heart rate. This result suggests that the fetus is likely to handle labor well.
Choice D rationale
A positive result in a CST indicates that the fetus has late decelerations in response to contractions, which can be a sign of fetal distress. This result may suggest fetal growth restriction, lower Apgar scores, and the potential need for cesarean delivery. However, this choice does not fully capture the significance of a positive CST result.