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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Thromboembolism.
Prolonged bed rest increases the risk of venous stasis and blood clot formation in the lower extremities, which can lead to pulmonary embolism if the clot dislodges and travels to the lungs.
This is a life-threatening complication that requires immediate treatment.
Choice B. Placental abruption is wrong because it is not caused by bed rest, but by trauma, hypertension, cocaine use, or other factors that can cause the placenta to separate from the uterine wall.
Choice C. Uterine atony is wrong because it is not caused by bed rest, but by overdistension of the uterus, prolonged labor, infection, or other factors that can impair the contraction of the uterine muscles after delivery.
Choice D. Infection is wrong because it is not caused by bed rest, but by poor hygiene, invasive procedures, or other factors that can introduce microorganisms into the reproductive tract.
Normal ranges for maternal heart rate are 60-100 beats per minute and blood pressure are 110-140/60-90 mm Hg.
Normal range for fetal heart rate is 110-160 beats per minute.
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