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

This is because assessing fetal heart rate is the most important action to take first when a client has prelabor rupture of membranes (PROM) at 34 weeks of gestation and oligohydramnios.Fetal heart rate can indicate fetal well-being, distress, or infection.Oligohydramnios can increase the risk of umbilical cord compression and fetal hypoxia.

Choice A is wrong because administering IV fluids is not the first priority in this situation.IV fluids may be given to prevent dehydration, enhance uterine blood flow, or augment labor, but they are not as urgent as assessing fetal heart rate.

Choice B is wrong because obtaining a urine specimen is not the first priority in this situation.A urine specimen may be obtained to check for infection, proteinuria, or glucose levels, but they are not as urgent as assessing fetal heart rate.

Choice D is wrong because inserting an indwelling urinary catheter is not the first priority in this situation.An indwelling urinary catheter may be inserted to monitor fluid balance, prevent bladder distension, or reduce the risk of infection, but they are not as urgent as assessing fetal heart rate.

Normal ranges for fetal heart rate are 110 to 160 beats per minute.Oligohydramnios is defined as an amniotic fluid index of less than 5 cm.

A. Accelerations B. Early decelerations C. Variable decelerations D. Absent variability

Correct Answer is D

Explanation

According to the search results, magnesium sulfate can have a negative effect on the fetal heart rate (FHR) by lowering the baseline, decreasing the variability, and reducing the reactivity or acceleration pattern.Absent variability means that there is no fluctuation in the FHR and it indicates fetal hypoxia or acidosis.

This is a potential adverse effect of magnesium sulfate on the fetus and requires immediate intervention.

Choice A.Accelerations is wrong because accelerations are transient increases in the FHR that indicate fetal well-being.They are not affected by magnesium sulfate.

Choice B.Early decelerations is wrong because early decelerations are decreases in the FHR that occur with uterine contractions and are caused by fetal head compression.They are benign and do not indicate fetal distress.They are not associated with magnesium sulfate.

Choice C.Variable decelerations is wrong because variable decelerations are abrupt decreases in the FHR that vary in shape, duration, and timing and are caused by umbilical cord compression.

They may or may not indicate fetal compromise.

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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

A nurse is admitting a client who is in pre-term labor at 34 weeks of gestation and has ruptured membranes and oligohydramnios. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is evaluating the fetal heart rate tracing of a client who is in pre-term labor and receiving magnesium sulfate. The nurse should identify that which of the following patterns indicates a potential adverse effect of the medication on the fetus?

Correct Answer is D

Explanation

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A nurse is administering betamethasone to a client who is at risk for pre-term labor at 30 weeks of gestation. Which of the following outcomes should the nurse monitor for in the newborn?

A nurse is providing discharge teaching to a client who delivered a pre-term newborn at 34 weeks of gestation. Which of the following instructions should the nurse include in the teaching?

A nurse is reviewing the ultrasound report of a client who is at 31 weeks of gestation and has pre-term labor. Which of the following findings indicates oligohydramnios?

A nurse is caring for a client who is receiving magnesium sulfate for pre-term labor. Which of the following assessments should the nurse perform to evaluate the therapeutic effect of the medication?

A nurse is evaluating a client who is at 28 weeks of gestation and has pre-term labor. Which of the following findings indicates that the client’s condition is improving?

A nurse is reviewing the medication history of a client who is in pre-term labor and has a history of peptic ulcer disease. The nurse should recognize that which of the following medications is contraindicated for this client?

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

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