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A nurse on an antepartum unit is caring for a 28-year-old gravida 1 para 0 female client at 32 weeks of gestation.

Exhibits

Complete the following sentence by using the list of options. The nurse should identify that _______ are findings that require follow-up.

Contractions every 5 minutes

Fetal heart rate of 140/min

Clear mucus discharge

Closed cervix

Answer and Explanation

The Correct Answer is A

The nurse should identify that contractions occurring every 5 minutes require follow-up for several reasons:

Preterm Labor Risk: At 32 weeks of gestation, regular contractions every 5 minutes could indicate the onset of preterm labor. This is concerning because preterm labor can lead to preterm birth, which poses significant risks to the baby's health and development.
Frequency and Intensity: These contractions are occurring frequently (every 5 minutes) and are described as stronger than usual Braxton Hicks contractions. This frequency and the strength of the contractions are unusual for Braxton Hicks, which are typically irregular and less intense.
Effacement and Cervical Changes: Although the cervix is closed, it is 80% effaced. Effacement means the cervix is thinning, which, in combination with regular contractions, may indicate that the body is preparing for labor.
Urinary Leakage: The client also reported urinary leakage earlier in the day, which could be a sign of ruptured membranes (water breaking). This, combined with regular contractions, increases the need for careful monitoring.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

Administration of IV fluids: This is anticipated as it ensures the client remains well-hydrated, which is important for both maternal and fetal health.
Continuous monitoring of FHR: This is anticipated to monitor the fetal well-being and ensure there are no signs of fetal distress.
Abdominal ultrasound: This is anticipated to assess fetal growth, amniotic fluid levels, and placental positioning.
Digital cervical exam to assess dilation and effacement: This is contraindicated because frequent cervical exams can increase the risk of infection and may cause unnecessary discomfort, especially if there are no signs of labor.
Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies: These tests are anticipated to provide important information about the client's blood count, blood type, Rh status, and coagulation parameters, which are crucial for managing potential complications.
Placement of an internal fetal spiral electrode: This is contraindicated as it is an invasive procedure that carries risks, and it is unnecessary given that the FHR is within normal limits with external monitoring.
Administration of betamethasone: This is anticipated as betamethasone is often given to promote fetal lung maturity in cases where there is a risk of preterm birth.

A. Check fetal heart tones. B. Prepare for a cesarean birth. C. Check the color, amount, and odor of the fluid. D. Perform Nitrazine test to assess for rupture of membranes.

Correct Answer is A

Explanation

Choice A rationale

Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.

Choice B rationale

Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.

Choice C rationale

Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.

Choice D rationale

Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.

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A nurse on an antepartum unit is caring for a 28-year-old gravida 1 para 0 female client at 32 weeks of gestation. Exhibits Complete the following sentence by using the list of options. The nurse should identify that _______ are findings that require follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

A client who is in active labor is admitted to a labor and delivery unit reporting "My water just broke and my baby is breech.”. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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A nurse on an antepartum unit is caring for a 28-year-old gravida 1 para 0 female client at 32 weeks of gestation.

Exhibits

Complete the following sentence by using the list of options. The nurse should identify that _______ are findings that require follow-up.