At a prenatal visit at 36 weeks' gestation, a client complains of discomfort with irregularly occurring contractions (Braxton Hicks contractions). The nurse instructs the client to:
Walk around and increase fluid intake.
Time contractions for 30 minutes.
Take aspirin for the discomfort.
Go to the hospital.
The Correct Answer is A
Choice A rationale
Walking and increasing fluid intake can often alleviate the discomfort associated with Braxton Hicks contractions. Movement can sometimes cause the uterus to relax, and adequate hydration helps maintain uterine irritability within normal physiological limits. Dehydration can sometimes exacerbate uterine contractions, so ensuring sufficient fluid intake is a prudent measure.
Choice B rationale
Timing contractions is more relevant when assessing for true labor. Braxton Hicks contractions are irregular and do not follow a consistent pattern of increasing frequency, duration, and intensity. Instructing the client to time them for 30 minutes may cause unnecessary anxiety and is not the primary intervention for discomfort relief.
Choice C rationale
Aspirin is not recommended during pregnancy, especially in the third trimester, due to potential risks to both the mother and the fetus, such as increased bleeding tendencies. Furthermore, aspirin would not address the physiological cause of Braxton Hicks contractions.
Choice D rationale
Going to the hospital is not indicated for irregular, non-painful Braxton Hicks contractions, especially at 36 weeks' gestation. Hospital visits are reserved for signs of true labor, such as regular, increasing contractions, rupture of membranes, or significant bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Placenta previa is a condition where the placenta implants in the lower part of the uterus, potentially covering the cervix. It typically presents with painless vaginal bleeding, especially in the later trimesters, and is not directly associated with sudden, intense abdominal pain and cessation of contractions during labor.
Choice B rationale
Uterine rupture is a serious complication of vaginal birth after cesarean (VBAC), especially with strong, frequent contractions. The sudden onset of intense abdominal pain and the cessation of contractions, along with fetal distress indicated by the absent fetal heart rate tracing, are classic signs of uterine rupture. The prior cesarean scar weakens the uterine wall, making it susceptible to tearing under the stress of labor.
Choice C rationale
A prolapsed umbilical cord occurs when the cord descends into the vagina ahead of the presenting part, potentially compressing the fetal blood vessels and causing fetal distress. While fetal heart rate abnormalities would be present, it is not typically associated with sudden, intense maternal abdominal pain and cessation of contractions.
Choice D rationale
Abruptio placentae is the premature separation of the placenta from the uterine wall. It can cause sudden abdominal pain, vaginal bleeding (though not always), and fetal distress. However, the cessation of uterine contractions is not a typical finding in abruptio placentae. Contractions may continue, although they might be accompanied by increased uterine tone.
Correct Answer is D
Explanation
Choice A rationale
The ventrogluteal muscle, located in the hip, is a safe site for intramuscular injections in adults and children older than seven months due to its distance from major nerves and blood vessels. However, the vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns and infants due to its well-developed muscle mass and accessibility.
Choice B rationale
The deltoid muscle, located in the upper arm, is small and not well-developed in newborns, making it an unsuitable site for intramuscular injections. There is also a risk of injury to the brachial nerve and blood vessels in this area in neonates.
Choice C rationale
The dorsogluteal muscle, located in the buttocks, is no longer the recommended site for intramuscular injections in infants and young children due to the proximity of the sciatic nerve and major blood vessels, increasing the risk of nerve damage.
Choice D rationale
The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the recommended site for intramuscular injections in newborns. It is a large, well-developed muscle that is easily accessible and away from major nerves and blood vessels, making it a safe and effective site for administering vitamin K to prevent hemorrhagic disease of the newborn.
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