A nurse is evaluating a client who is at 28 weeks of gestation and has pre-term labor.
Which of the following findings indicates that the client’s condition is improving?
Decreased frequency and intensity of contractions
Increased cervical dilation and effacement
Increased amount and color of vaginal discharge
Decreased fetal heart rate variability
The Correct Answer is A
Decreased frequency and intensity of contractions indicates that the client’s condition is improving. Preterm labor occurs when regular contractions result in the opening of your cervix before 37 weeks of pregnancy.
If preterm labor can’t be stopped, your baby will be born early and may have health problems.
Choice B is wrong because increased cervical dilation and effacement means that the cervix is thinning and opening more, which are signs of labor progression.
Choice C is wrong because increased amount and color of vaginal discharge may indicate infection, bleeding, or rupture of membranes, which are complications of preterm labor.
Choice D is wrong because decreased fetal heart rate variability means that the baby’s heart rate is not changing much, which may indicate fetal distress or hypoxia. A normal fetal heart rate variability is between 6 and 25 beats per minute.
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Correct Answer is C
Explanation
Magnesium sulfate is a drug that is used to prevent seizures associated with pre-eclampsia and to stop preterm labor.However, it can also cause adverse effects such as respiratory depression, which is a condition where the breathing rate becomes too slow and shallow.
Respiratory depression can be life-threatening for both the mother and the baby, so the nurse should monitor the client’s respiratory rate and oxygen saturation closely.
Choice A is wrong because magnesium sulfate can cause hypotension, not hypertension.Hypotension is low blood pressure, which can lead to dizziness, fainting, and shock.
Choice B is wrong because magnesium sulfate can cause hyporeflexia, not hyperreflexia.Hyporeflexia is a reduced or absent reflex response, which can indicate magnesium toxicity.
The nurse should check the client’s deep tendon reflexes regularly and stop the infusion if they are absent.
Choice D is wrong because magnesium sulfate can cause bradycardia, not tachycardia.
Bradycardia is a slow heart rate, which can reduce the blood flow to vital organs.
Correct Answer is A
Explanation
Leukocoria (white pupils) is a symptom of retinopathy of prematurity (ROP), an eye disease that can happen in premature babies.ROP happens when abnormal blood vessels grow on the retina, the light-sensitive layer of tissue in the back of the eye.
Choice B is wrong because strabismus (crossed eyes) is not a symptom of ROP, but a possible complication that can occur later in life.
Choice C is wrong because nystagmus (involuntary eye movements) is not a symptom of ROP, but another possible complication that can occur later in life.
Choice D is wrong because it includes choices B and C, which are incorrect.
Normal ranges for gestational age and birth weight are 38 to 42 weeks and 5.5 to 10 pounds, respectively.Babies born before 31 weeks or weighing less than 3 pounds are at risk for ROP.
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