While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital.
The nurse's teaching was effective when the patient states that she will come when she:
Feels increased fetal movement.
Thinks her membranes have ruptured.
Has contractions that are 10 minutes apart.
Has mild abdominal or groin discomfort.
The Correct Answer is B
Choice A rationale
Increased fetal movement is normal and usually not a sign to head to the hospital unless there are other concerns.
Choice B rationale
Ruptured membranes can signify the beginning of labor or risk for infection, warranting a visit to the hospital for assessment.
Choice C rationale
Contractions that are 10 minutes apart typically indicate early labor, but not necessarily the need to go to the hospital immediately.
Choice D rationale
Mild abdominal or groin discomfort can occur during pregnancy and does not immediately warrant a hospital visit without other signs of labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale: Initiating continuous electronic fetal monitoring is essential to assess the fetal heart rate and detect any signs of fetal distress. Given the history of decreased fetal movements, it's crucial to monitor the baby's condition closely.
Choice B rationale: Administering magnesium sulfate is recommended for neuroprotection in preterm deliveries, particularly for pregnancies less than 32-34 weeks gestation. It helps reduce the risk of cerebral palsy in preterm infants.
Choice C rationale: Performing a sterile speculum exam is unnecessary since the rupture of membranes has already been confirmed through the presence of amniotic fluid pooling and positive ferning test results.
Choice D rationale: Preparing the client for an emergency C-section is not immediately necessary unless there are signs of fetal distress or other complications. The priority is to stabilize the client's condition and monitor both the mother and the baby.
Choice E rationale: Monitoring for signs of chorioamnionitis is crucial since the client presents with ruptured membranes. Chorioamnionitis is a potential infection that can occur with prolonged rupture of membranes, which can lead to maternal and fetal complications. Monitoring includes assessing for fever, uterine tenderness, and foul-smelling amniotic fluid.
Correct Answer is D
Explanation
Choice A rationale
Premature rupture of the membranes refers to the breaking of the amniotic sac before labor starts. It is not a definitive indicator of true labor, as contractions and cervical changes need to accompany it to confirm labor onset.
Choice B rationale
Light irregular pattern of contractions is often associated with false labor or Braxton Hicks contractions. True labor contractions are typically regular, progressively stronger, and closer together.
Choice C rationale
3 station of the presenting part refers to the baby's descent into the pelvis. While it indicates labor progression, it is not the most definitive sign of true labor compared to cervical changes.
Choice D rationale
Progressive cervical dilation is the most reliable indicator of true labor. It signifies that the cervix is opening up in response to regular and effective contractions, indicating the body is preparing for childbirth.
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