The nurse is caring for the pregnant client. Which assessment findings

Maternal NCLEX

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Question 1 of 5.

The nurse is caring for the pregnant client. Which assessment findings help the nurse determine that she may be in true labor? Select all that apply.

A. Progressive cervical dilation and effacement

B. Walking usually increases contraction intensity

C. Warm tub baths and rest lessen contractions

D. Discomfort is usually in the client's abdomen

E. Contractions increase in duration and intensity

Explanation: Progressive cervical dilation and effacement indicate true labor. In false labor, the contractions may occur for several hours, but there is no cervical change. In true labor, walking usually increases the intensity of contractions. In false labor, walking usually has little or no effect on contractions and may sometimes decrease the frequency, intensity, and duration of contractions. Contractions increase in duration and intensity during true labor, while there is usually no change in contractions during false labor. Warm tub baths and rest lessen contractions during false labor. In true labor, contractions do not decrease with warm tub baths or rest. Discomfort is usually in the client's abdomen during false labor. Discomfort begins in the back and radiates around to the abdomen during true labor.

Question 2 of 5.

The nurse correctly explains that the bleeding is the result of sloughing of which structure?

A. Endometrium

B. Myometrium

C. Epimetrium

D. None of the above

Explanation: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.

Question 3 of 5.

On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?

A. 5 months

B. 6 months

C. 7 months

D. 8 months

Explanation: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.

Question 4 of 5.

The nurse correctly assists the client into which position?

A. Lithotomy

B. Prone

C. Sims'

D. Trendelenburg's

Explanation: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.

Question 5 of 5.

Which response by the nurse is most accurate?

A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.

B. Hepatitis B surface antigen (HBsAg) test can detect this defect.

C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.

D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.

Explanation: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.