A primigravida arrives at the maternity unit’s observation area because she believes she is in labor.
The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes.
Which assessment finding would confirm to the nurse that the client is not in labor at this time?
A.
Cervical dilation is 1 cm.
B.
Contractions decrease with walking.
C.
There is 2+ pitting edema in the lower extremities.
D.
The membranes are intact.
The Correct Answer and Explanation is:
The correct answer is A. Cervical dilation is 1 cm.
To determine if a primigravida (a woman who is pregnant for the first time) is in labor, the nurse assesses several key factors, including the pattern of contractions, cervical changes, and other physiological signs. In this scenario, the fetal heart rate is within the normal range (140 beats per minute), and contractions are occurring irregularly every 10 to 15 minutes, which are characteristics often associated with early labor or even Braxton Hicks contractions.
Cervical dilation is a critical indicator of whether a woman is in true labor. True labor is characterized by progressive cervical changes, including dilation and effacement. A dilation of 1 cm suggests that the cervix has not significantly changed, and therefore the labor is not advancing. In contrast, during active labor, cervical dilation progresses more significantly, typically from 3 cm to 10 cm.
Option B, “Contractions decrease with walking,” suggests that the contractions are not strong enough to indicate active labor. True labor contractions tend to become more intense and closer together with activity.
Option C, “There is 2+ pitting edema in the lower extremities,” while a notable finding, is not a direct indicator of labor status. It may indicate fluid retention but does not provide insight into cervical changes or contraction patterns.
Option D, “The membranes are intact,” is also a relevant finding, as ruptured membranes typically occur during labor; however, intact membranes alone do not rule out the possibility of labor.
In summary, the assessment finding that confirms the client is not in labor is cervical dilation of 1 cm, as true labor is marked by progressive cervical changes, which are not evident in this case.