A nurse is teaching a client who is at 27 weeks of gestation and has pre-term labor about the signs and symptoms of true labor versus false labor.
Which of the following information should the nurse include in the teaching?
True labor contractions are irregular and subside with rest
False labor contractions are felt in the lower back and radiate to the abdomen
True labor contractions cause cervical dilation and effacement
False labor contractions increase in intensity with ambulation
The Correct Answer is C
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%.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Tocolytics are a category of drugs used to delay the labor process.These may be used in situations when a pregnant person begins showing signs of preterm labor —which is any time before 37 weeks of completed pregnancy.Tocolytics may help delay labor by two to seven days.
Some possible explanations for the other choices are:
• Choice A. Administering intravenous fluids.
This is not a correct answer because intravenous fluids are not effective in suppressing uterine contractions.They may be used to correct dehydration or electrolyte imbalance, which can sometimes trigger preterm labor, but they are not a primary intervention for preterm labor.
• Choice C. Administering corticosteroids.
This is not a correct answer because corticosteroids are not tocolytics.They do not stop or slow down uterine contractions, but they help accelerate fetal lung maturity and reduce the risk of neonatal respiratory distress syndrome and other complications of prematurity.
Corticosteroids are often given along with tocolytics, but they have a different function and mechanism of action.
• Choice D. Administering antibiotics.
This is not a correct answer because antibiotics are not tocolytics.They may be used to treat infections that can cause or complicate preterm labor, such as chorioamnionitis or group B streptococcus, but they do not directly affect uterine contractions.
Antibiotics may be given along with tocolytics, but they have a different function.
Correct Answer is B
Explanation
Tachycardia.
Terbutaline is a medication that can be used to stop or delay preterm labor by relaxing the uterine muscles.However, it can also cause serious side effects for both the mother and the baby.One of the most common side effects of terbutaline is tachycardia, which means a fast or irregular heartbeat.This can lead to chest pain, palpitations, shortness of breath, and even cardiac arrhythmias or ischemia.
Therefore, the nurse should monitor the mother’s heart rate and rhythm closely when administering terbutaline.
Choice A is wrong because terbutaline does not cause hypotension, which means low blood pressure.In fact, terbutaline can increase blood pressure by constricting blood vessels.
Choice C is wrong because terbutaline does not cause hyperglycemia, which means high blood sugar.However, terbutaline can interfere with insulin secretion and glucose metabolism in some cases, especially in diabetic mothers.
Therefore, the nurse should monitor the mother’s blood sugar levels when administering terbutaline.
Choice D is wrong because terbutaline does not cause hypokalemia, which means low potassium levels in the blood.However, terbutaline can cause a temporary increase in potassium levels in the baby, which can affect the baby’s heart function.
Therefore, the nurse should monitor the baby’s heart rate and rhythm when administering terbutaline.
Normal ranges for heart rate are 60 to 100 beats per minute for adults and 120 to 160 beats per minute for fetuses.
Normal ranges for blood pressure aretypically between 90/60 mmHg and 120/80 mmHg.
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