A nurse is teaching a client who is at risk for pre-term labor about the signs and symptoms to report to the provider.
Which of the following should the nurse include in the teaching?
Decreased fetal movement
Increased vaginal discharge
Pelvic pressure
All of the above
The Correct Answer is D
All of the above. The nurse should include all of these signs and symptoms in the teaching as they may indicate pre-term labor. Pre-term labor occurs when regular contractions begin to open the cervix before 37 weeks of pregnancy.
Choice A is wrong because decreased fetal movement is not a normal sign of pre-term labor, but it may indicate fetal distress or other complications.
Choice B is wrong because increased vaginal discharge is not a normal sign of pre-term labor, but it may indicate infection or rupture of membranes.
Choice C is wrong because pelvic pressure is not a normal sign of pre-term labor, but it may indicate cervical dilation or descent of the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Infection on speculum examination.
Infection is a major cause of preterm labor and can lead to serious complications for the mother and the fetus.
Infection can be detected by a speculum examination that shows signs of inflammation, such as erythema, edema, discharge, or odor.
Infection can also be confirmed by laboratory tests, such as culture, gram stain, or polymerase chain reaction.Infection should be treated promptly with antibiotics and other supportive measures.
Choice B. Bleeding on speculum examination is wrong because bleeding is not a direct cause of preterm labor, but rather a sign of other conditions that may increase the risk of preterm labor, such as placenta previa, placental abruption, or cervical trauma.Bleeding should be evaluated further to determine the source and severity of the hemorrhage and to manage any complications.
Choice C. Positive fetal fibronectin test (FFN) is wrong because a positive FFN test indicates the presence of fetal fibronectin in the cervical or vaginal secretions, which is a marker of increased risk of preterm labor, but not a definitive marker.
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