A nurse is planning discharge teaching for a client who is at 25 weeks of gestation and has pre-term labor that was successfully stopped with tocolytic therapy.

Which of the following instructions should the nurse include in the teaching?

Avoid sexual intercourse until term

Drink at least 3 L of fluids per day

Report any increase in vaginal discharge to the provider

Perform pelvic floor exercises daily

Answer and Explanation

The Correct Answer is C

Report any increase in vaginal discharge to the provider. This is because an increase in vaginal discharge can indicate an infection, which can trigger preterm labor or cause complications for the mother and the baby.

Choice A is wrong because sexual intercourse is not contraindicated for women who have preterm labor that was successfully stopped with tocolytic therapy, unless they have other risk factors such as placenta previa or ruptured membranes.

Choice B is wrong because drinking at least 3 L of fluids per day is not necessary for women who have preterm labor that was successfully stopped with tocolytic therapy, unless they have dehydration or oligohydramnios.

Choice D is wrong because pelvic floor exercises are not recommended for women who have preterm labor that was successfully stopped with tocolytic therapy, as they can increase uterine activity and cause contractions.

Tocolytic therapy is the use of drugs to delay delivery for a short time (up to 48 hours) if a woman begins labor too early in her pregnancy.

The purpose of tocolytic therapy is to allow time for the administration of corticosteroids or other medicine.

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Correct Answer is C

Explanation

True labor contractions cause cervical dilation and effacement.

This means that the cervix opens up and thins out to prepare for the baby’s passage through the birth canal.

Cervical changes can be measured by a pelvic exam.

Choice A is wrong because true labor contractions are regular and do not subside with rest.False labor contractions are irregular and may stop when you change position or activity level.

Choice B is wrong because false labor contractions are usually felt in the front of the abdomen, not in the lower back.True labor contractions may start in the back and radiate to the abdomen.

Choice D is wrong because false labor contractions do not increase in intensity with ambulation.True labor contractions may become stronger and closer together when you walk.

Normal ranges for cervical dilation and effacement vary depending on the stage of labor, but generally, full dilation is 10 cm and full effacement is 100%.

A. Administer a dose of tocolytic medication B. Encourage the client to rest in a side-lying position C. Assess fetal heart rate using a Doppler device D. Assess vaginal discharge for any change

Correct Answer is C

Explanation

Assess fetal heart rate using a Doppler device.

This is because low back pain and pelvic pressure at 36 weeks of gestation may indicate preterm labor, which can affect the fetal well-being.Therefore, the nurse should assess the fetal heart rate as a priority to determine if the fetus is in distress or not.

Choice A is wrong because tocolytic medication is used to stop uterine contractions, not to relieve low back pain and pelvic pressure.Choice B is wrong because resting in a side-lying position may help with blood circulation and reduce supine hypotensive syndrome, but it does not address the possible cause of low back pain and pelvic pressure.Choice D is wrong because assessing vaginal discharge for any change may indicate infection, rupture of membranes, or cervical dilation, but it is not as urgent as assessing fetal heart rate.

Some interventions for preventing and treating low back pain and pelvic pressure during pregnancy include exercise, water-based exercise, acupuncture, osteomanipulative therapy, craniosacral therapy, and pelvic support belts.

However, these interventions should be discussed with the health care provider before starting them.

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A nurse is planning discharge teaching for a client who is at 25 weeks of gestation and has pre-term labor that was successfully stopped with tocolytic therapy. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

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Correct Answer is C

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Correct Answer is C

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A nurse is planning discharge teaching for a client who is at 25 weeks of gestation and has pre-term labor that was successfully stopped with tocolytic therapy.

Which of the following instructions should the nurse include in the teaching?