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 B

Explanation

Prepare for an emergency cesarean section.This is because the client has pre-term labor that has not responded to tocolytic therapy, which are drugs that are used to delay delivery for a short time.The client’s cervix is dilated to 4 cm and she is experiencing regular contractions every 3 minutes, which are signs of active labor.The baby is at 33 weeks of gestation, which is premature and may have complications such as respiratory distress syndrome or bleeding in the brain.

Therefore, the client needs an emergency cesarean section to deliver the baby as soon as possible and prevent further risks.

Choice A is wrong because administering magnesium sulfate intravenously is a type of tocolytic therapy that the client has already failed.Magnesium sulfate may also have side effects such as nausea, vomiting, flushing, headache, and muscle weakness.

Choice C is wrong because placing the client in Trendelenburg position, which is lying on the back with the feet elevated above the head, is not recommended for preterm labor.This position may increase the risk of aspiration, decrease cardiac output, and impair gas exchange.

Choice D is wrong because administering antibiotics prophylactically is not indicated for preterm labor unless there is evidence of infection in the uterus or membranes.

Antibiotics may also cause allergic reactions or bacterial resistance

A. Measure urine output B. Check deep tendon reflexes C. Assess uterine activity D. Monitor blood pressure

Correct Answer is C

Explanation

The therapeutic effect of magnesium sulfate is to inhibit uterine contractions and prevent or delay preterm labor.

By assessing uterine activity, the nurse can evaluate if the medication is working or not.

Choice A is wrong because measuring urine output is not directly related to the therapeutic effect of magnesium sulfate, but rather to monitor for toxicity and renal function.

Choice B is wrong because checking deep tendon reflexes is also not directly related to the therapeutic effect of magnesium sulfate, but rather to monitor for neuromuscular effects and toxicity.

Choice D is wrong because monitoring blood pressure is not directly related to the therapeutic effect of magnesium sulfate, but rather to monitor for cardiovascular effects and toxicity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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?

Correct Answer is C

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?