The clinic nurse is caring for a client at 31 weeks gestation who is scheduled for induction of labor at 42 weeks gestation.
Which teaching is a priority for this client?
Methods of labor induction.
Benefits of breastfeeding.
Signs of labor.
Monitoring of fetal movement.
The Correct Answer is D
Choice A rationale
While understanding methods of labor induction is important if the pregnancy progresses to 42 weeks, it is not the priority teaching at 31 weeks gestation. The immediate focus should be on recognizing potential complications that could arise before the scheduled induction.
Choice B rationale
The benefits of breastfeeding are important for all pregnant women but are not the priority teaching for a client at 31 weeks who is not yet in labor. Information about breastfeeding can be provided later in the pregnancy.
Choice C rationale
Teaching the signs of labor is important as the client approaches term, but at 31 weeks, the priority is to educate the client on recognizing potential warning signs that require immediate attention, such as decreased fetal movement.
Choice D rationale
Monitoring fetal movement is a crucial teaching point at 31 weeks gestation. A decrease in fetal movement can be an early indicator of fetal compromise and requires prompt evaluation. Instructing the client on how to perform kick counts and when to report changes is a priority for ensuring fetal well-being before the scheduled induction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
G represents gravida, the total number of pregnancies, including the current one (2). T represents term births, the number of pregnancies delivered at 37 weeks gestation or later (1). P represents preterm births, the number of pregnancies delivered between 20 and 36 weeks gestation (0). A represents abortions, the number of pregnancies ending before 20 weeks gestation (0). L represents living children (1).
Choice B rationale
This option incorrectly states L as 2. The client has one living child from the previous pregnancy.
Choice C rationale
This option incorrectly states P as 1. The client's previous pregnancy was delivered at 38 weeks, which is considered a term birth, not preterm.
Choice D rationale
This option incorrectly states G as 3. The client is currently pregnant with twins, making this her second pregnancy in total.
Correct Answer is []
Explanation
Rationale for Correct Condition
Preterm labor is defined as the onset of regular contractions leading to cervical change before 37 weeks of gestation. This client’s symptoms, including uterine contractions every 4–5 minutes, cervical effacement of 50%, a positive fetal fibronectin test, and shortened cervical length, strongly indicate preterm labor rather than pyelonephritis, placental abruption, or cervical insufficiency.
Rationale for Correct Actions
Magnesium sulfate functions as a tocolytic, suppressing contractions by inhibiting calcium influx in myometrial cells, thereby delaying preterm birth and reducing neonatal complications. Betamethasone accelerates fetal lung maturity by increasing surfactant production, reducing the risk of neonatal respiratory distress syndrome if preterm delivery occurs.
Rationale for Correct Parameters
Cervical effacement is a direct indicator of labor progression, showing changes in cervical thinning that accompany dilation. Monitoring effacement allows assessment of tocolytic effectiveness. Contraction frequency reveals labor severity and the response to magnesium sulfate. Persistent contractions despite treatment indicate the need for additional interventions.
Rationale for Incorrect Conditions
Pyelonephritis causes systemic symptoms like fever, flank pain, and bacteremia rather than uterine contractions and cervical changes. Placental abruption typically presents with painful vaginal bleeding and uterine tenderness, which are absent here. Cervical insufficiency is painless and lacks regular contractions, with cervical changes occurring silently rather than progressively.
Rationale for Incorrect Actions
Urine culture identifies infection but does not directly treat preterm labor. RhoGAM is necessary for Rh-negative individuals, which is irrelevant in this case. IV hydration may help with contractions but is not a primary intervention.
Rationale for Incorrect Parameters
Flank pain suggests pyelonephritis rather than preterm labor. Vaginal bleeding is associated with abruption or miscarriage, not preterm labor without cervical rupture. Fetal heart rate variability is useful in fetal assessment but does not directly indicate labor progression.
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