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
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.
Correct Answer is A
Explanation
Choice A rationale
This statement is incorrect. Vagus nerve stimulation actually decreases FHR variability. The vagus nerve, part of the parasympathetic nervous system, slows the heart rate and reduces variability.
Choice B rationale
This statement is correct. Baroreceptors are sensors located in blood vessels that help regulate blood pressure by detecting changes in the stretch of the vessel walls. They play a crucial role in maintaining stable blood pressure levels.
Choice C rationale
This statement is correct. The autonomic nervous system, which includes the sympathetic and parasympathetic nervous systems, controls the fetal heart rate. It regulates the balance between heart rate acceleration and deceleration.
Choice D rationale
This statement is correct. Chemoreceptors respond to changes in blood gas levels, such as oxygen and carbon dioxide. They help regulate respiratory and cardiovascular responses to maintain homeostasis.