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 B
Explanation
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 corticosteroids and transfer to a tertiary care facility if necessary.
Choice A is wrong because administering intravenous fluids does not reduce uterine activity.It may be used to correct dehydration or electrolyte imbalance, which can be risk factors for preterm labor.
Choice C is wrong because administering corticosteroids does not reduce uterine activity.It may be used to enhance fetal lung maturity and reduce the risk of neonatal complications such as respiratory distress syndrome, intracranial hemorrhage, and necrotizing enterocolitis.
Choice D is wrong because administering antibiotics does not reduce uterine activity.It may be used to treat infections that can trigger preterm labor, such as bacterial vaginosis or chorioamnionitis.
Correct Answer is C
Explanation
Haemorrhage due to placental abruption.
Placental abruption is a serious complication of preterm labor that occurs when the placenta separates from the wall of the uterus before delivery.This can cause heavy bleeding and endanger the life of both the mother and the baby.
Choice A is wrong because increased fetal movement is not a complication of preterm labor.In fact, decreased fetal movement may indicate fetal distress.
Choice B is wrong because decreased uterine contractions are not a complication of preterm labor.Preterm labor is defined as regular contractions that result in the opening of the cervix before 37 weeks of pregnancy.
Choice D is wrong because increased cervical dilation is not a complication of preterm labor, but a sign of it.Cervical dilation indicates that the cervix is preparing for delivery and may lead to preterm birth.
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