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
Dizziness can be a side effect of epidural anesthesia, but it is not as critical as hypotension. It should be monitored, but it does not require immediate reporting unless it is severe or accompanied by other symptoms.
Choice B rationale
Blood pressure of 88/52 mmHg indicates hypotension, which is a common and potentially serious side effect of epidural anesthesia. Hypotension can lead to decreased placental perfusion and fetal distress, so it requires immediate attention and reporting to the anesthesia provider.
Choice C rationale
A pain level of 1 on a 0 to 10 scale indicates that the epidural is effectively managing the client’s pain. This is a positive outcome and does not require reporting.
Choice D rationale
A pulse of 88 bpm is within the normal range for an adult and does not indicate any immediate concern that needs to be reported to the anesthesia provider.
Correct Answer is A
Explanation
Choice A rationale
A non-stress test (NST) is a common test used to evaluate fetal well-being, especially in cases of decreased fetal movement. It measures the fetal heart rate in response to its movements. A reactive NST, where the fetal heart rate increases with movement, indicates good oxygenation and neurological function.
Choice B rationale
A contraction stress test (CST) evaluates the fetal heart rate response to uterine contractions, which can be induced by oxytocin or nipple stimulation. It is typically used to assess placental function and fetal tolerance to labor, not for initial assessment of decreased fetal movement.
Choice C rationale
A biophysical profile (BPP) combines an NST with ultrasound to assess fetal breathing, movement, tone, and amniotic fluid volume. While comprehensive, it is more time-consuming and usually reserved for further evaluation if the NST is non-reactive.
Choice D rationale
An ultrasound can assess fetal growth, amniotic fluid volume, and anatomical structures. However, it does not provide real-time information on fetal heart rate reactivity, making it less suitable for immediate assessment of decreased fetal movement.