A nurse is reviewing the history of a client who is pregnant.
Which of the following clinical data indicates the client is at risk for preterm delivery?
Previous delivery at 37 weeks gestation
Previous delivery of a newborn weighing 2.5 kg (5.5 lb)
Previous reactive non-stress test
Previous cervical cerclage
The Correct Answer is D
Choice A rationale
A previous delivery at 37 weeks gestation does not necessarily indicate a risk for preterm delivery. Preterm delivery is defined as delivery before 37 weeks of gestation.
Choice B rationale
A previous delivery of a newborn weighing 2.5 kg (5.5 lb) does not indicate a risk for preterm delivery. Low birth weight can be a result of preterm delivery, but it can also be due to other factors such as intrauterine growth restriction.
Choice C rationale
A previous reactive non-stress test does not indicate a risk for preterm delivery. A reactive non-stress test is a positive sign of fetal well-being.
Choice D rationale
A previous cervical cerclage indicates a risk for preterm delivery. Cervical cerclage is a procedure performed to prevent preterm birth in women with a history of preterm birth and who have a short cervix.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
• Neonatal hypoglycemia: The newborn’s blood glucose level is 30 mg/dL, which is below the normal range. This, along with the jitteriness, weak cry, and mottled skin with acrocyanosis, suggests the newborn is most likely experiencing neonatal hypoglycemia.
• Actions to take: The nurse should administer a 10% dextrose IV bolus as prescribed by the provider to increase the newborn’s blood glucose levels. The nurse should also monitor the newborn’s blood glucose levels every 30 minutes to ensure they are increasing towards the normal range.
• Parameters to monitor: The nurse should monitor the newborn’s blood glucose levels to ensure they are increasing towards the normal range. The nurse should also monitor the newborn’s heart rate, as tachycardia can be a sign of hypoglycemia. If the newborn’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.
Correct Answer is C
Explanation
Choice A rationale
Intramuscular injection in the right deltoid is not the preferred route for administering phytonadione to a newborn.
Choice B rationale
Subcutaneous injection in the right deltoid is not the preferred route for administering phytonadione to a newborn.
Choice C rationale
Intramuscular injection in the left vastus lateralis is the preferred route for administering phytonadione to a newborn. This muscle in the thigh is large enough to absorb the medication effectively.
Choice D rationale
Subcutaneous injection in the left vastus lateralis is not the preferred route for administering phytonadione to a newborn.
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