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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?

A.

Uterine contractions that cause variable decelerations.

B.

Regular uterine contractions that cause cervical change.

C.

Station of the presenting part.

D.

Rupture of the membranes resulting in uterine contractions.

Answer and Explanation

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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View Related questions

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

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.

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