A nurse is teaching a client who is pregnant about the risk factors for pre-term labor.
Which of the following statements by the client indicates a need for further teaching?
“I should avoid smoking and drinking alcohol during pregnancy.”
“I should report any vaginal bleeding or fluid leakage to my provider.”
“I should limit my physical activity and rest as much as possible.”
“I should drink plenty of fluids and eat a balanced diet.”.
The Correct Answer is C
The client should not limit their physical activity and rest as much as possible, unless advised by their provider. Excessive rest and inactivity can increase the risk of blood clots and decrease blood circulation, which can affect the placenta and the fetus. The client should follow the recommended guidelines for physical activity during pregnancy, unless they have a medical condition that requires bed rest or reduced activity.
Choice A is wrong because smoking and drinking alcohol during pregnancy are known risk factors for preterm labor and birth. Smoking can reduce blood flow to the placenta and affect fetal growth and development, while alcohol can cause fetal alcohol spectrum disorders and other complications.
Choice B is wrong because reporting any vaginal bleeding or fluid leakage to the provider is important to prevent or treat preterm labor and birth. Bleeding can indicate placenta previa or placental abruption, which are serious conditions that can cause premature delivery or fetal distress. Fluid leakage can indicate rupture of membranes, which can increase the risk of infection and preterm labor.
Choice D is wrong because drinking plenty of fluids and eating a balanced diet are beneficial for the health of the mother and the fetus. Dehydration can cause uterine contractions and trigger preterm labor, while malnutrition can affect fetal growth and development. A balanced diet can also help prevent or manage conditions like diabetes, high blood pressure, and anemia, which are risk factors for preterm labor and birth.
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 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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