A nurse is caring for a 26-year-old female client who is at 26 weeks of gestation in the antepartum unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Rationale for Correct Condition
Preterm labor is defined as the onset of regular contractions leading to cervical change before 37 weeks of gestation. This client’s symptoms, including uterine contractions every 4–5 minutes, cervical effacement of 50%, a positive fetal fibronectin test, and shortened cervical length, strongly indicate preterm labor rather than pyelonephritis, placental abruption, or cervical insufficiency.
Rationale for Correct Actions
Magnesium sulfate functions as a tocolytic, suppressing contractions by inhibiting calcium influx in myometrial cells, thereby delaying preterm birth and reducing neonatal complications. Betamethasone accelerates fetal lung maturity by increasing surfactant production, reducing the risk of neonatal respiratory distress syndrome if preterm delivery occurs.
Rationale for Correct Parameters
Cervical effacement is a direct indicator of labor progression, showing changes in cervical thinning that accompany dilation. Monitoring effacement allows assessment of tocolytic effectiveness. Contraction frequency reveals labor severity and the response to magnesium sulfate. Persistent contractions despite treatment indicate the need for additional interventions.
Rationale for Incorrect Conditions
Pyelonephritis causes systemic symptoms like fever, flank pain, and bacteremia rather than uterine contractions and cervical changes. Placental abruption typically presents with painful vaginal bleeding and uterine tenderness, which are absent here. Cervical insufficiency is painless and lacks regular contractions, with cervical changes occurring silently rather than progressively.
Rationale for Incorrect Actions
Urine culture identifies infection but does not directly treat preterm labor. RhoGAM is necessary for Rh-negative individuals, which is irrelevant in this case. IV hydration may help with contractions but is not a primary intervention.
Rationale for Incorrect Parameters
Flank pain suggests pyelonephritis rather than preterm labor. Vaginal bleeding is associated with abruption or miscarriage, not preterm labor without cervical rupture. Fetal heart rate variability is useful in fetal assessment but does not directly indicate labor progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hypotonic uterine dysfunction typically occurs in the active phase of labor (after 4 cm cervical dilation) and is characterized by weak, infrequent, and ineffective contractions that do not lead to cervical change. The client in the latent phase with slow cervical change is not yet in the active phase.
Choice B rationale
The latent phase of the first stage of labor is characterized by irregular, mild to moderate contractions that cause slow, gradual cervical dilation and effacement. It can be lengthy, especially in primigravidas, and the discomfort can be significant. A cervical dilation of 2 cm with no change in 3 hours in the presence of painful, erratic contractions every 5 to 10 minutes aligns with a normal latent phase.
Choice C rationale
Hypertonic uterine dysfunction usually occurs in the latent phase and is characterized by frequent, uncoordinated, and strong contractions that are ineffective in causing cervical dilation or effacement. While the contractions are painful, they are not described as excessively strong or uncoordinated, and the client is in the expected early stage of labor.
Choice D rationale
Precipitous labor is a very rapid labor and delivery, typically lasting less than 3 hours from the onset of regular contractions to expulsion of the fetus. The client's labor is progressing slowly, with minimal cervical change over 3 hours, which is the opposite of precipitous labor.
Correct Answer is A
Explanation
Choice A rationale
Methergine (methylergonovine) is an oxytocic medication that causes vasoconstriction and increases blood pressure. It is contraindicated in clients with hypertension. Therefore, assessing the client's blood pressure before administration is crucial to ensure safety. Normal adult blood pressure is typically less than 120/80 mmHg.
Choice B rationale
Assessing uterine tone is important in managing postpartum hemorrhage, as a boggy uterus contributes to bleeding. However, before administering a medication that affects blood pressure, the blood pressure itself is the priority assessment due to the contraindications of Methergine in hypertensive clients.
Choice C rationale
Deep tendon reflexes are assessed in the postpartum period, particularly for clients with preeclampsia who are at risk for magnesium sulfate toxicity. While important, it is not the priority assessment before administering Methergine, which has a direct impact on blood pressure.
Choice D rationale
Assessing the amount of lochia is essential for monitoring postpartum bleeding. However, before administering Methergine, which can significantly increase blood pressure, ensuring the client does not have a contraindication related to hypertension is the most critical immediate assessment. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.