A nurse is caring for a client who has been admitted to an antepartum unit.
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History and Physical
Day 1, 0900:
30-year-old client who is at 33 weeks of gestation, gravida 4 para 3. Maternal blood type is Rh positive. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks of gestation. No known allergies.
Nurses' Notes
Day 1, 0900:
Client reports lower back pain and pinkish vaginal discharge.
Uterine contractions every 8 min, palpate strong, duration 30 seconds.
FHR baseline is 145/min, minimal variability.
Cervical examination indicates 2 cm, 50% effaced, 0 station.
Membranes are intact.
CBC and urinalysis collected and sent to laboratory.
Client reports lower back pain and pinkish vaginal discharge
Uterine contractions every 8 min, palpate strong, duration 30 seconds.
FHR baseline is 145/min, minimal variability.
Cervical examination indicates 2 cm, 50% effaced, 0 station.
Membranes are intact.
The Correct Answer is ["A","B","C","D"]
Rationale for correct choices
• Lower back pain and pinkish vaginal discharge: Pinkish vaginal discharge, often called “bloody show,” is a sign of cervical changes and indicates progression of labor. In combination with lower back pain, contractions and cervical effacement, it suggests that preterm labor may be underway and requires close monitoring.
• Uterine contractions every 8 min, palpate strong, duration 30 seconds: Regular, strong contractions in the third trimester can signal preterm labor. Given the client’s history of preterm birth, this finding warrants close monitoring and possible interventions to halt labor progression or enhance fetal lung maturity.
• FHR baseline 145/min, minimal variability: Minimal variability in the fetal heart rate can indicate fetal hypoxia or stress. Continuous monitoring and assessment of maternal-fetal status are necessary to identify potential complications and guide interventions.
• Cervical examination 2 cm, 50% effaced: Cervical changes at 33 weeks indicate early cervical ripening, consistent with preterm labor. This finding requires follow-up to evaluate progression and implement appropriate interventions to prevent preterm birth.
Rationale for incorrect choices
• Membranes intact: Intact membranes indicate that preterm premature rupture of membranes has not occurred. This is reassuring and does not require immediate intervention, although ongoing assessment is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Providing clients with information about the benefits of exercise: Educating clients on exercise is an example of primary prevention, aimed at promoting overall health and preventing the onset of disease in healthy individuals.
B. Using an electronic messaging system to remind clients when to take medications: This is an example of tertiary prevention because it helps manage an existing condition (HIV) and prevents complications by promoting adherence to treatment, reducing disease progression and related morbidity.
C. Helping clients understand health screenings covered by their insurance plans: Assisting clients with preventive screenings falls under secondary prevention, which focuses on early detection and prompt intervention to reduce disease impact.
D. Educating clients about contraindications to specific immunizations: Teaching about vaccine contraindications is part of primary prevention, aiming to prevent illness before it occurs by ensuring safe immunization practices.
Correct Answer is C
Explanation
A. Atrial fibrillation: Atrial fibrillation is characterized by absent P waves and an irregularly irregular ventricular rhythm. A constant P-R interval is not observed in this dysrhythmia.
B. Complete heart block: Complete heart block (third-degree AV block) shows no relationship between P waves and QRS complexes, with atrial and ventricular rhythms independent of each other. A constant prolonged P-R interval is not present.
C. First-degree atrioventricular block: First-degree AV block is defined by a consistently prolonged P-R interval (>0.20 seconds) with all atrial impulses conducted to the ventricles. A P-R interval of 0.35 seconds indicates delayed AV conduction consistent with first-degree AV block.
D. Premature atrial complexes: Premature atrial complexes present as early P waves with abnormal morphology, often followed by a normal QRS. The P-R interval may be normal or slightly altered, but a consistently prolonged P-R interval is not characteristic.
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