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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
History of urinary tract infections.According to the Mayo Clinic, untreated vaginal infections, such as urinary tract infections or sexually transmitted infections, are risk factors for preterm labor.
These infections can cause inflammation and irritation of the cervix, which can trigger contractions and cervical dilation.
Choice B is wrong because maternal age of 25 years is not a risk factor for preterm labor.In fact, women younger than 18 or older than 35 are more likely to have a preterm delivery.
Choice C is wrong because singleton pregnancy is not a risk factor for preterm labor.On the contrary, being pregnant with twins, triplets, or more (called "multiple gestations") is associated with a higher risk of preterm labor and birth.
Choice D is wrong because cervical length of 3 cm is not a risk factor for preterm labor.A short cervix (less than 2.5 cm) or a cervix that shortens in the second trimester instead of the third trimester is a risk factor for preterm delivery.A normal cervical length ranges from 3 to 5 cm during pregnancy.
Correct Answer is A
Explanation
Assess fetal heart rate and activity.
The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk forpremature rupture of membranes (PROM), which can lead toinfection,cord prolapse, andfetal distress.Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.
Choice B is wrong because performing a nitrazine test on the fluid is not the first action.A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.
Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation.Oxytocin is used to induce or augment labor, but it can causeuterine hyperstimulation,fetal distress, andplacental abruptionif given to a client who has PROM.
Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM.Trendelenburg position can increase the risk ofcord prolapseandaspirationin this situation.
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