A nurse is assessing a client for pre-term labor.
Which of the following assessments should the nurse prioritize?
Obtaining a detailed history of previous pregnancies
Checking the fetal heart rate and activity
Performing a speculum examination of the vagina and cervix
Performing laboratory tests, such as urine culture
The Correct Answer is C
Performing a speculum examination of the vagina and cervix.
This is because a speculum examination can help determine the presence of cervical dilation, effacement, or infection, which are signs of pre-term labor.
A speculum examination can also detect the presence of fetal fibronectin, which is a protein that indicates an increased risk of pre-term delivery.
Choice A is wrong because obtaining a detailed history of previous pregnancies is not a priority assessment for pre-term labor.
While it can provide some information about the client’s risk factors, it does not indicate the current status of the pregnancy or the cervix.
Choice B is wrong because checking the fetal heart rate and activity is not a priority assessment for pre-term labor.
While it can provide some information about the fetal well-being, it does not indicate the presence or absence of contractions or cervical changes.
Choice D is wrong because performing laboratory tests, such as urine culture, is not a priority assessment for pre-term labor.
While it can help identify possible infections that may contribute to pre-term labor, it does not provide immediate results or indicate the current status of the cervix.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Maintaining a neutral head position.This action can help reduce the client’s risk of intraventricular hemorrhage (IVH) by preventing fluctuations in intracranial pressure that could rupture blood vessels in the brain.
Choice A is wrong because encouraging early ambulation can increase the risk of IVH by causing changes in blood pressure and cerebral perfusion.
Choice B is wrong because administering medications to induce hypercoagulability can increase the risk of IVH by promoting thrombosis and impairing blood flow to the brain.
Choice C is wrong because monitoring the client’s blood glucose levels is not directly related to the prevention of IVH, although it may be important for other reasons such as avoiding hypoglycemia or hyperglycemia.
Correct Answer is C
Explanation
Hypoglycemia due to low glycogen stores.
Premature newborns have low glycogen stores and are at risk of developing hypoglycemia, which can cause seizures, brain damage, or death.
The nurse should monitor the blood glucose levels of the newborn and report any signs of hypoglycemia, such as jitteriness, lethargy, poor feeding, or temperature instability.
Choice A is wrong because increased bilirubin levels, not decreased, are a potential complication of prematurity.
Bilirubin is a waste product of red blood cell breakdown that can accumulate in the blood and cause jaundice, a yellowing of the skin and eyes.
Premature newborns have immature livers that cannot process bilirubin effectively and may need phototherapy to reduce the levels.
Choice B is wrong because decreased fat stores, not increased, are a potential complication of prematurity.
Fat stores provide insulation and energy for the newborn and help maintain body temperature.
Premature newborns have less subcutaneous fat and are prone to heat loss and cold stress, which can affect their metabolism and oxygen consumption.
Choice D is wrong because absence of mature lung surfactant, not presence, is a potential complication of prematurity.
Surfactant is a substance that reduces the surface tension of the alveoli and prevents them from collapsing during expiration.
Premature newborns have insufficient surfactant production and may develop respiratory distress syndrome, which is characterized by tachypnea, grunting, retractions, and cyanosis.
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