A nurse is caring for a 28-year-old female client in the emergency department. The client is experiencing symptoms suggesting the risk of preterm birth.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should identify that the client is at the greatest risk for preterm birth due to fetal fibronectin:
dropdown
and
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

The nurse should identify that the client is at the greatest risk for preterm birth due to:

Response 1: B) being higher than normal (fetal fibronectin: 0.09 mcg/mL is higher than the normal level of ≤ 0.05 mcg/mL).

Response 2: B) Nitrazine and ferning tests negative

Here's the

Fetal Fibronectin: Fetal fibronectin is a protein found between the amniotic sac and the uterine lining. Levels greater than 0.05 mcg/mL (like 0.09 mcg/mL) indicate an increased risk of preterm labor.
Nitrazine and Ferning Tests: Both tests being negative indicates that there is no rupture of membranes. Even though these tests are negative, the elevated fetal fibronectin level still indicates a risk for preterm birth.

So the completed sentence would be: The nurse should identify that the client is at the greatest risk for preterm birth due to fetal fibronectin being higher than normal and Nitrazine and ferning tests negative.

This combination of findings suggests that preterm labor may be imminent despite the lack of membrane rupture. The elevated fetal fibronectin is a strong indicator of risk.

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Correct Answer is A

Explanation

Choice A rationale

A respiratory rate of 12/min indicates that the respiratory depression caused by magnesium sulfate toxicity has been effectively reversed by calcium gluconate. Normal respiratory rate in adults is 12-20 breaths per minute.

Choice B rationale

Absent deep tendon reflexes indicate ongoing magnesium sulfate toxicity. Calcium gluconate administration should restore normal reflexes, not cause their absence.

Choice C rationale

Slurred speech is a sign of magnesium sulfate toxicity. Effective treatment with calcium gluconate should improve neurological function and resolve symptoms like slurred speech.

Choice D rationale

A urine output of 22 mL/hr is below the normal range and suggests renal impairment or ongoing toxicity. Effective treatment should result in an increase in urine output to within the normal range (greater than 30 mL/hr).

A. Uterine contractions every 15 min. B. FHR baseline 166/min with minimal variability. C. Late decelerations in FHR. D. Contraction duration of 75 seconds.

Correct Answer is D

Explanation

Choice A rationale

Uterine contractions occur more frequently than every 15 minutes during the active phase of labor, typically every 2-3 minutes.

Choice B rationale

A fetal heart rate baseline of 166/min is considered tachycardia and may not be normal during labor.

Choice C rationale

Late decelerations are concerning and not expected as they may indicate fetal distress.

Choice D rationale

Contractions lasting about 75 seconds are expected during the active phase of labor.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has preeclampsia and received a dose of calcium gluconate to treat magnesium sulfate toxicity.Which of the following findings should the nurse identify as an indication that calcium gluconate was effective?

Correct Answer is A

Explanation

A nurse is monitoring a client who is in the active phase of labor and has an electronic fetal monitor.Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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