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 C

Explanation

The client should not limit their physical activity and rest as much as possible, unless advised by their provider.Excessive rest and inactivity can increase the risk of blood clots and decrease blood circulation, which can affect the placenta and the fetus.The client should follow the recommended guidelines for physical activity during pregnancy, unless they have a medical condition that requires bed rest or reduced activity.

Choice A is wrong because smoking and drinking alcohol during pregnancy are known risk factors for preterm labor and birth.Smoking can reduce blood flow to the placenta and affect fetal growth and development, while alcohol can cause fetal alcohol spectrum disorders and other complications.

Choice B is wrong because reporting any vaginal bleeding or fluid leakage to the provider is important to prevent or treat preterm labor and birth.Bleeding can indicate placenta previa or placental abruption, which are serious conditions that can cause premature delivery or fetal distress.Fluid leakage can indicate rupture of membranes, which can increase the risk of infection and preterm labor.

Choice D is wrong because drinking plenty of fluids and eating a balanced diet are beneficial for the health of the mother and the fetus.Dehydration can cause uterine contractions and trigger preterm labor, while malnutrition can affect fetal growth and development.A balanced diet can also help prevent or manage conditions like diabetes, high blood pressure, and anemia, which are risk factors for preterm labor and birth.

A. Avoid sexual intercourse until term B. Drink at least 3 L of fluids per day C. Report any increase in vaginal discharge to the provider D. Perform pelvic floor exercises daily

Correct Answer is C

Explanation

Report any increase in vaginal discharge to the provider.This is because an increase in vaginal discharge can indicate an infection, which can trigger preterm labor or cause complications for the mother and the baby.

Choice A is wrong because sexual intercourse is not contraindicated for women who have preterm labor that was successfully stopped with tocolytic therapy, unless they have other risk factors such as placenta previa or ruptured membranes.

Choice B is wrong because drinking at least 3 L of fluids per day is not necessary for women who have preterm labor that was successfully stopped with tocolytic therapy, unless they have dehydration or oligohydramnios.

Choice D is wrong because pelvic floor exercises are not recommended for women who have preterm labor that was successfully stopped with tocolytic therapy, as they can increase uterine activity and cause contractions.

Tocolytic therapy is the use of drugs to delay delivery for a short time (up to 48 hours) if a woman begins labor too early in her pregnancy.

The purpose of tocolytic therapy is to allow time for the administration of corticosteroids or other medicine.

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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 C

Explanation

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Correct Answer is C

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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?