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

Exhibits

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client. There must be at least one selection in every row. There does not need to be a selection in every column.

Administration of IV fluids

Continuous monitoring of FHR

Abdominal ultrasound

Digital cervical exam to assess dilation and effacement

Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies

Placement of an internal fetal spiral electrode

Administration of betamethasone

Answer and Explanation

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

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.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale

Music can be a non-pharmacological method to help manage pain and anxiety during the latent phase of labor.

Choice B rationale

Biofeedback might be helpful but can be challenging to implement without prior training.

Choice C rationale

Administering fentanyl 100 mg every hour is not appropriate; fentanyl is typically administered in much smaller doses.

Choice D rationale

A pudendal nerve block is usually reserved for the second stage of labor or delivery, not the latent phase.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

The nurse should identify that the client is at the greatest risk for preterm birth due to:

Response 1: B) being higher than normal (fetal fibronectin: 0.09 mcg/mL is higher than the normal level of ≤ 0.05 mcg/mL).

Response 2: B) Nitrazine and ferning tests negative

Here's the

Fetal Fibronectin: Fetal fibronectin is a protein found between the amniotic sac and the uterine lining. Levels greater than 0.05 mcg/mL (like 0.09 mcg/mL) indicate an increased risk of preterm labor.
Nitrazine and Ferning Tests: Both tests being negative indicates that there is no rupture of membranes. Even though these tests are negative, the elevated fetal fibronectin level still indicates a risk for preterm birth.

So the completed sentence would be: The nurse should identify that the client is at the greatest risk for preterm birth due to fetal fibronectin being higher than normal and Nitrazine and ferning tests negative.

This combination of findings suggests that preterm labor may be imminent despite the lack of membrane rupture. The elevated fetal fibronectin is a strong indicator of risk.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who is in the latent phase of labor.Which of the following interventions should the nurse include in the plan to manage the client's pain?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

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