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
Decreased frequency and intensity of contractions indicates that the client’s condition is improving.Preterm labor occurs when regular contractions result in the opening of your cervix before 37 weeks of pregnancy.
If preterm labor can’t be stopped, your baby will be born early and may have health problems.
Choice B is wrong because increased cervical dilation and effacement means that the cervix is thinning and opening more, which are signs of labor progression.
Choice C is wrong because increased amount and color of vaginal discharge may indicate infection, bleeding, or rupture of membranes, which are complications of preterm labor.
Choice D is wrong because decreased fetal heart rate variability means that the baby’s heart rate is not changing much, which may indicate fetal distress or hypoxia.A normal fetal heart rate variability is between 6 and 25 beats per minute.
Correct Answer is A
Explanation
Nitrazine paper test.
This test involves putting a drop of fluid obtained from the vagina onto paper strips containing nitrazine dye.
The strips change color depending on the pH of the fluid.The strips will turn blue if the pH is greater than 6.0, which indicates the presence of amniotic fluid.This test can help confirm rupture of membranes (ROM) in pregnancy, especially when preterm labor is suspected.
Choice B. Ferning test.This test involves examining a sample of vaginal fluid under a microscope and looking for a fern-like pattern that is formed by dried amniotic fluid crystals.This test can also help confirm ROM, but it is less reliable than the nitrazine test because other substances such as cervical mucus, semen, or blood can also cause ferning.
Choice C. Amniotic fluid index.This test involves measuring the amount of amniotic fluid in the uterus using ultrasound.This test can help assess the fetal well-being and detect conditions such as oligohydramnios (low amniotic fluid) or polyhydramnios (high amniotic fluid).This test cannot confirm ROM by itself, but it can be used in combination with other tests to evaluate the status of the pregnancy.
Choice D. Biophysical profile.This test involves using ultrasound and a fetal monitor to assess the fetal heart rate, breathing, movement, muscle tone, and amniotic fluid volume.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.