A nurse is caring for a client in pre-term labor and suspects an infection.
Which assessment finding would support this suspicion?
Decreased fetal heart rate
Increased uterine contractions
Decreased fluid intake
Decreased cervical changes
The Correct Answer is A
A decrease in fetal heart rate can indicate fetal distress due to infection, hypoxia, or cord compression.
Normal fetal heart rate is between 110 and 160 beats per minute.
Choice B. Increased uterine contractions is wrong because it is a normal sign of pre-term labor and does not necessarily indicate infection.
Choice C. Decreased fluid intake is wrong because it is not a specific sign of infection and can have other causes such as nausea, vomiting, or decreased thirst.
Choice D. Decreased cervical changes is wrong because it is also not a specific sign of infection and can indicate ineffective contractions or cervical incompetence.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Monitoring cervical changes.
This is because cervical changes indicate the progress of labor and the risk of preterm delivery.
Preterm labor is defined as regular uterine contractions with cervical dilation and effacement before 37 weeks of gestation.
The nurse should assess the cervical length, dilation, effacement, and position frequently to determine the need for interventions to stop or delay labor.
Choice A is wrong because monitoring vital signs is not specific to fetal well-being.
Vital signs can reflect maternal health, infection, or complications, but they do not directly measure fetal status.
Choice C is wrong because monitoring fluid intake and output is not specific to fetal well-being.
Fluid balance can affect maternal hydration, electrolytes, and blood pressure, but it does not directly measure fetal status.
Choice D is wrong because monitoring maternal preference is not specific to fetal well-being.
Maternal preference can affect the comfort, satisfaction, and coping of the mother, but it does not directly measure fetal status.
Correct Answer is B
Explanation
The correct answer is choice B. Administering tocolytics.Tocolytics are drugs that inhibit uterine contractions and can delay preterm labor for a short time.This can allow time for the administration of antenatal corticosteroids and transfer to a tertiary care facility if necessary.
Choice A is wrong because administering intravenous fluids does not improve blood flow to the placenta and fetus.It may also increase the risk of pulmonary edema in women with preterm labor.
Choice C is wrong because administering corticosteroids does not improve blood flow to the placenta and fetus.Corticosteroids are given to enhance fetal lung maturity and reduce the risk of neonatal complications such as respiratory distress syndrome, intracranial hemorrhage, and necrotizing enterocolitis.
However, they do not stop preterm labor.
Choice D is wrong because providing emotional support does not improve blood flow to the placenta and fetus.Emotional support is important for women with preterm labor, but it is not a priority intervention to prevent fetal hypoxia or acidosis.
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