A client treated for preterm labor is to be discharged to home. Which instruction should a nurse include in this client’s discharge plan? The client should:.
Document urine output hourly.
Avoid sexual intercourse.
Maintain a darkened, quiet environment.
Eat small, frequent meals.
The Correct Answer is B
The correct answer is choice B. The client should avoid sexual intercourse. Sexual intercourse may stimulate uterine contractions and increase the risk of preterm labor. The client should also avoid activities that may cause dehydration, infection, or stress.
Choice A is wrong because documenting urine output hourly is not necessary for a client with preterm labor who is discharged home. Urine output may be affected by hydration status, kidney function, or medication use, but it is not a reliable indicator of preterm labor.
Choice C is wrong because maintaining a darkened, quiet environment is not required for a client with preterm labor who is discharged home. The client may benefit from rest and relaxation, but there is no evidence that light or noise affects preterm labor.
Choice D is wrong because eating small, frequent meals is not specific to a client with preterm labor who is discharged home. Eating small, frequent meals may help with nausea, heartburn, or blood sugar control, but it does not prevent preterm labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.
Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.
Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.
Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.
It does not indicate fetal distress.
Normal ranges for fetal heart rate patterns are:
• Baseline: 120-160 beats per minute
• Variability: 6-25 beats per minute
• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds
• Decelerations: none or early (mirror contractions)
Correct Answer is D
Explanation
Braxton Hicks contractions are irregular, painless uterine contractions that occur throughout pregnancy, but are more noticeable in the third trimester.They do not indicate labor, but rather help in softening and ripening the cervix.
Choice A is wrong because the patient does not need to time the contractions unless they become regular, painful, and closer together, which are signs of true labor.
Choice B is wrong because documenting fetal activity daily is not related to Braxton Hicks contractions.Fetal activity is monitored to assess fetal well-being and detect any signs of fetal distress.
Choice C is wrong because losing the mucus plug is also not related to Braxton Hicks contractions.The mucus plug is a thick plug of mucus that seals the cervical canal during pregnancy and may be expelled before or during labor.
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