The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor? Select all that apply.

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11ecbb05_cc0d_ce5f_b433_d97f1ae66a4f_MD0009_00 True labor is defined as contractions that cause progressive cervical change over time. Probable signs of labor are identified by assessing the timing and intensity of contractions, the success of comfort measures in relieving the pain, and the location of the pain (Options B and E). Consistent, intense contractions that get stronger and closer together (more frequent over time) and are associated with lower back discomfort that radiates to the abdomen are indicative of true labor (Options A and D). If a woman is experiencing Braxton Hicks contractions (ie, "false labor"), the nurse should provide encouragement and education about signs of labor and suggest comfort measures. Comfort measures relieve maternal anxiety, increase coping, and encourage normal progression of labor. The nurse may suggest walking, taking a warm bath, resting in a lateral position, having a snack, staying hydrated, and voiding often. (Option C) During pregnancy, a collection of secretions forms a "mucous plug" in the cervical canal, acting as a protective barrier. Although the client may notice expulsion of the mucous plug in the days preceding labor, it is not necessarily a sign of labor. Educational objective: True labor is defined as contractions that cause progressive cervical change over time. Consistent, intense contractions that get stronger and closer together and are associated with lower back discomfort that radiates to the abdomen are indicative of probable labor.

The Nurse Is Performing Telephone Triage with a Client at 38