63. A nurse is observing a primigravida client admitted in active labor. Which observation would be the most reliable guide to assess the progression of the client's labor?
63. A nurse is observing a primigravida client admitted in active labor. Which observation would be the most reliable guide to assess the progression of the client's labor?
. Vaginal discharge that is increasing.
. Breathing that is becoming more rapid.
. Contractions that are getting more intense.
. Cervix that is progressively dilating.
Test-Taking Tip
This question is asking for the definition of progress of labor. Eliminate the answers that do not define labor progress.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
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Answer 1 is incorrect because vaginal discharge that is increasing is not a reliable method of assessing progress of labor. The only method for reliably evaluating the progress of labor is a cervical examination. Labor is defined as a change in the cervix. Answer 2 is incorrect because breathing that is becoming more rapid is not a reliable method of assessing progress of labor. Clients have different pain tolerance, and breathing may change in response to pain; only checking the cervix for a change in dilation is a reliable method to assess the progress of labor. Answer 3 is incorrect because contractions that are getting more intense is not a reliable method of assessing progress of labor. The definition of labor is a change in the cervix; stronger contractions may lead to a change in the cervix. The intensity of the contractions alone is not indicative of progress in labor. Answer 4 is correct because a cervix that is progressively dilating is the definition of labor progress.