A nurse is assessing a client for pre-term labor.
Which assessment finding would be most concerning and require immediate intervention?
Infection on speculum examination
Bleeding on speculum examination
Positive fetal fibronectin test (FFN)
Normal fetal heart rate and activity
The Correct Answer is A
Infection on speculum examination.
Infection is a major cause of preterm labor and can lead to serious complications for the mother and the fetus.
Infection can be detected by a speculum examination that shows signs of inflammation, such as erythema, edema, discharge, or odor.
Infection can also be confirmed by laboratory tests, such as culture, gram stain, or polymerase chain reaction. Infection should be treated promptly with antibiotics and other supportive measures.
Choice B. Bleeding on speculum examination is wrong because bleeding is not a direct cause of preterm labor, but rather a sign of other conditions that may increase the risk of preterm labor, such as placenta previa, placental abruption, or cervical trauma. Bleeding should be evaluated further to determine the source and severity of the hemorrhage and to manage any complications.
Choice C. Positive fetal fibronectin test (FFN) is wrong because a positive FFN test indicates the presence of fetal fibronectin in the cervical or vaginal secretions, which is a marker of increased risk of preterm labor, but not a definitive marker.
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Related Questions
Correct Answer is C
Explanation
True labor contractions cause cervical dilation and effacement.
This means that the cervix opens up and thins out to prepare for the baby’s passage through the birth canal.
Cervical changes can be measured by a pelvic exam.
Choice A is wrong because true labor contractions are regular and do not subside with rest.False labor contractions are irregular and may stop when you change position or activity level.
Choice B is wrong because false labor contractions are usually felt in the front of the abdomen, not in the lower back.True labor contractions may start in the back and radiate to the abdomen.
Choice D is wrong because false labor contractions do not increase in intensity with ambulation.True labor contractions may become stronger and closer together when you walk.
Normal ranges for cervical dilation and effacement vary depending on the stage of labor, but generally, full dilation is 10 cm and full effacement is 100%.
Correct Answer is A
Explanation
A white blood cell count of 12,000/mm3 indicates an infection that can trigger pre-term labor.The normal range for white blood cell count in pregnancy is 5.7-15.0×10 9 /L, which is equivalent to 5,700-15,000/mm3.
A count above this range suggests an inflammatory response to an infection.
Choice B is wrong because a hemoglobin level of 11 g/dL is within the normal range for pregnancy, which is 10-14 g/dL.
Choice C is wrong because a platelet count of 250,000/mm3 is within the normal range for pregnancy, which is 150,000-400,000/mm3.
Choice D is wrong because a blood glucose level of 90 mg/dL is within the normal range for pregnancy, which is 70-110 mg/dL.
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