A nurse is performing a physical examination on a client suspected of pre-term labor.
Which assessment finding should the nurse report immediately?
Elevated blood glucose level
Thinning of the cervix
Positive fetal fibronectin test (FFN)
Abdominal tenderness
The Correct Answer is C
A positive fetal fibronectin test (FFN) indicates that the fetal membrane has been disrupted and labor may occur within the next 7 to 14 days.
This is a sign of preterm labor that should be reported immediately.
Choice A is wrong because elevated blood glucose level is not a sign of preterm labor, but a possible complication of gestational diabetes.
Choice B is wrong because thinning of the cervix (also called effacement) is a normal process that occurs during late pregnancy and labor.
It does not necessarily indicate preterm labor.
Choice D is wrong because abdominal tenderness is not a specific sign of preterm labor.
It could be caused by other factors such as constipation, gas, or stretching of the ligaments.
Some of the signs and symptoms of preterm labor include:
• Regular or frequent sensations of abdominal tightening (contractions) every 10 minutes or more often
• Change in vaginal discharge (leaking fluid or bleeding from the vagina)
• Feeling of pressure in the pelvis (hip) area
• Low, dull backache
• Cramps that feel like menstrual cramps
• Abdominal cramps with or without diarrhea
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A positive fetal fibronectin test (FFN) indicates that the fetal membrane has been disrupted and labor may occur within the next 7 to 14 days.
This is a sign of preterm labor that should be reported immediately.
Choice A is wrong because elevated blood glucose level is not a sign of preterm labor, but a possible complication of gestational diabetes.
Choice B is wrong because thinning of the cervix (also called effacement) is a normal process that occurs during late pregnancy and labor.
It does not necessarily indicate preterm labor.
Choice D is wrong because abdominal tenderness is not a specific sign of preterm labor.
It could be caused by other factors such as constipation, gas, or stretching of the ligaments.
Some of the signs and symptoms of preterm labor include:
• Regular or frequent sensations of abdominal tightening (contractions) every 10 minutes or more often
• Change in vaginal discharge (leaking fluid or bleeding from the vagina)
• Feeling of pressure in the pelvis (hip) area
• Low, dull backache
• Cramps that feel like menstrual cramps
• Abdominal cramps with or without diarrhea
Correct Answer is C
Explanation
Fetal heart rate decelerations indicate fetal distress because they reflect a decrease in blood flow or oxygen to the fetus.
Choice A is wrong because a fetal heart rate of 150/min is within the normal range of 110-160 bpm.Choice B is wrong because a fetal heart rate variability of 10/min is considered moderate and reassuring.Choice D is wrong because fetal heart rate accelerations are a sign of fetal well-being and indicate that the fetus is responding to stimuli.
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