A nurse is assessing a client for pre-term labor.

Which assessment finding would be most concerning and require immediate intervention?

Infection on speculum examination

Bleeding on speculum examination

Positive fetal fibronectin test (FFN)

Normal fetal heart rate and activity

Answer and Explanation

The Correct Answer is A

Infection on speculum examination.

Infection is a major cause of preterm labor and can lead to serious complications for the mother and the fetus.

Infection can be detected by a speculum examination that shows signs of inflammation, such as erythema, edema, discharge, or odor.

Infection can also be confirmed by laboratory tests, such as culture, gram stain, or polymerase chain reaction. Infection should be treated promptly with antibiotics and other supportive measures.

Choice B. Bleeding on speculum examination is wrong because bleeding is not a direct cause of preterm labor, but rather a sign of other conditions that may increase the risk of preterm labor, such as placenta previa, placental abruption, or cervical trauma. Bleeding should be evaluated further to determine the source and severity of the hemorrhage and to manage any complications.

Choice C. Positive fetal fibronectin test (FFN) is wrong because a positive FFN test indicates the presence of fetal fibronectin in the cervical or vaginal secretions, which is a marker of increased risk of preterm labor, but not a definitive marker.

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Correct Answer is A

Explanation

A. Referral to community services for support.

Referral to community services for support is an important part of the discharge plan for a client in preterm labor.Community services can provide education, counseling, home visits, and other resources to help the client cope with preterm labor and prevent complications.

B. Encouragement to smoke in moderation.Statement is wrong because smoking is harmful for the unborn baby and can increase the risk of preterm labor.Smoking should be avoided completely during pregnancy and the client should be advised to quit or seek help to quit.

C. Instructions for heavy lifting and strenuous exercise.Statement is wrong because heavy lifting and strenuous exercise can trigger contractions and worsen preterm labor.The client should be instructed to rest as much as possible and avoid activities that may cause uterine irritation or bleeding.

D. Recommendation to avoid kangaroo care.Statement is wrong because kangaroo care, or skin-to-skin contact with the baby, is beneficial for both the mother and the baby after birth.Kangaroo care can help regulate the baby’s temperature, heart rate, breathing, and blood sugar levels, as well as promote bonding, breastfeeding, and infection prevention.The client should be encouraged to practice kangaroo care as soon as possible after delivery.

A. Nitrazine paper test B. Ferning test C. Amniotic fluid index D. Biophysical profile

Correct Answer is A

Explanation

Nitrazine paper test.

This test involves putting a drop of fluid obtained from the vagina onto paper strips containing nitrazine dye.

The strips change color depending on the pH of the fluid.The strips will turn blue if the pH is greater than 6.0, which indicates the presence of amniotic fluid.This test can help confirm rupture of membranes (ROM) in pregnancy, especially when preterm labor is suspected.

Choice B. Ferning test.This test involves examining a sample of vaginal fluid under a microscope and looking for a fern-like pattern that is formed by dried amniotic fluid crystals.This test can also help confirm ROM, but it is less reliable than the nitrazine test because other substances such as cervical mucus, semen, or blood can also cause ferning.

Choice C. Amniotic fluid index.This test involves measuring the amount of amniotic fluid in the uterus using ultrasound.This test can help assess the fetal well-being and detect conditions such as oligohydramnios (low amniotic fluid) or polyhydramnios (high amniotic fluid).This test cannot confirm ROM by itself, but it can be used in combination with other tests to evaluate the status of the pregnancy.

Choice D. Biophysical profile.This test involves using ultrasound and a fetal monitor to assess the fetal heart rate, breathing, movement, muscle tone, and amniotic fluid volume.

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A nurse is assessing a client for pre-term labor. Which assessment finding would be most concerning and require immediate intervention?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is assessing a client for pre-term labor.

Which assessment finding would be most concerning and require immediate intervention?