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

Answer and Explanation

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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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%.

A. Referral to community services for support B. Encouragement to smoke in moderation C. Instructions for heavy lifting and strenuous exercise D. Recommendation to avoid kangaroo care

Correct Answer is A

Explanation

A. Referral to community services for support.

Referral to community services for support is an important part of the discharge plan for a client in preterm labor.Community services can provide education, counseling, home visits, and other resources to help the client cope with preterm labor and prevent complications.

B. Encouragement to smoke in moderation.Statement is wrong because smoking is harmful for the unborn baby and can increase the risk of preterm labor.Smoking should be avoided completely during pregnancy and the client should be advised to quit or seek help to quit.

C. Instructions for heavy lifting and strenuous exercise.Statement is wrong because heavy lifting and strenuous exercise can trigger contractions and worsen preterm labor.The client should be instructed to rest as much as possible and avoid activities that may cause uterine irritation or bleeding.

D. Recommendation to avoid kangaroo care.Statement is wrong because kangaroo care, or skin-to-skin contact with the baby, is beneficial for both the mother and the baby after birth.Kangaroo care can help regulate the baby’s temperature, heart rate, breathing, and blood sugar levels, as well as promote bonding, breastfeeding, and infection prevention.The client should be encouraged to practice kangaroo care as soon as possible after delivery.

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A nurse is assessing a client for pre-term labor. Which assessment finding would be most concerning and require immediate intervention?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is at 27 weeks of gestation and has pre-term labor about the signs and symptoms of true labor versus false labor. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A client in pre-term labor is being discharged from the hospital. What should the nurse include in the client's discharge plan?

Correct Answer is A

Explanation

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A nurse is caring for a client who is at 32 weeks of gestation and has signs of pre-term labor. Which of the following tests should the nurse anticipate to confirm ROM?

A nurse is providing education to a client who had pre-term labor and was prescribed indomethacin. Which of the following information should the nurse include in the teaching?

A nurse is assessing a client for pre-term labor.

Which assessment finding would be most concerning and require immediate intervention?