A nurse is caring for a 26-year-old female client who is at 26 weeks of gestation in the antepartum unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Rationale for Correct Condition
Preterm labor is defined as the onset of regular contractions leading to cervical change before 37 weeks of gestation. This client’s symptoms, including uterine contractions every 4–5 minutes, cervical effacement of 50%, a positive fetal fibronectin test, and shortened cervical length, strongly indicate preterm labor rather than pyelonephritis, placental abruption, or cervical insufficiency.
Rationale for Correct Actions
Magnesium sulfate functions as a tocolytic, suppressing contractions by inhibiting calcium influx in myometrial cells, thereby delaying preterm birth and reducing neonatal complications. Betamethasone accelerates fetal lung maturity by increasing surfactant production, reducing the risk of neonatal respiratory distress syndrome if preterm delivery occurs.
Rationale for Correct Parameters
Cervical effacement is a direct indicator of labor progression, showing changes in cervical thinning that accompany dilation. Monitoring effacement allows assessment of tocolytic effectiveness. Contraction frequency reveals labor severity and the response to magnesium sulfate. Persistent contractions despite treatment indicate the need for additional interventions.
Rationale for Incorrect Conditions
Pyelonephritis causes systemic symptoms like fever, flank pain, and bacteremia rather than uterine contractions and cervical changes. Placental abruption typically presents with painful vaginal bleeding and uterine tenderness, which are absent here. Cervical insufficiency is painless and lacks regular contractions, with cervical changes occurring silently rather than progressively.
Rationale for Incorrect Actions
Urine culture identifies infection but does not directly treat preterm labor. RhoGAM is necessary for Rh-negative individuals, which is irrelevant in this case. IV hydration may help with contractions but is not a primary intervention.
Rationale for Incorrect Parameters
Flank pain suggests pyelonephritis rather than preterm labor. Vaginal bleeding is associated with abruption or miscarriage, not preterm labor without cervical rupture. Fetal heart rate variability is useful in fetal assessment but does not directly indicate labor progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The client at 6 weeks gestation exhibiting severe abdominal pain, hypotension (86/58 mm Hg), and tachycardia (132/min) suggests a potential ruptured ectopic pregnancy or other acute abdominal emergency requiring immediate intervention. Hypotension indicates inadequate tissue perfusion, and tachycardia is a compensatory mechanism to maintain cardiac output. Severe pain further indicates an acute process that necessitates prompt assessment and treatment to prevent further hemodynamic instability and potential life-threatening complications.
Choice B rationale
While a client with an ectopic pregnancy requires monitoring and care, the vital signs reported (blood pressure 128/84 mm Hg, pulse 88/min) are within normal limits. Normal blood pressure ranges are typically systolic 90-120 mm Hg and diastolic 60-80 mm Hg, and a normal pulse rate is generally 60-100 beats per minute. Although emotional distress from the diagnosis is important, the physiological parameters do not indicate an immediate critical threat compared to the client in Choice A.
Choice C rationale
A client at 9 weeks gestation who received methotrexate for an ectopic pregnancy and reports moderate pain and dizziness with stable vital signs (blood pressure 116/80 mm Hg, pulse 86/min) requires assessment for expected side effects of the medication or signs of treatment failure. Methotrexate can cause abdominal pain as it works to dissolve the pregnancy. While monitoring is necessary, the stable vital signs do not suggest an immediate life-threatening emergency compared to the client in Choice A.
Choice D rationale
A client at 8 weeks gestation with moderate vaginal bleeding, minimal abdominal pain, and stable vital signs (blood pressure 118/72 mm Hg, pulse 96/min) may be experiencing a threatened or inevitable miscarriage. While vaginal bleeding in early pregnancy warrants investigation and monitoring, the stable vital signs and minimal pain do not indicate an immediate critical emergency requiring prioritization over the client in Choice A who presents with signs of hemodynamic instability. .
Correct Answer is A
Explanation
Choice A rationale
A reactive non-stress test indicates fetal well-being. The criteria for a reactive NST in a fetus greater than 32 weeks gestation include two or more fetal heart rate accelerations of at least 15 beats per minute above the baseline lasting for at least 15 seconds within a 20-minute period. The baseline fetal heart rate should be within the normal range of 110 to 160 beats per minute. This client's results meet these criteria.
Choice B rationale
A non-reactive non-stress test lacks the required number of fetal heart rate accelerations or the accelerations do not meet the amplitude or duration criteria within the specified time frame. This suggests the fetus may be experiencing some form of stress and requires further evaluation.
Choice C rationale
A negative non-stress test is not a standard term used to describe NST results. The test is categorized as either reactive (indicating fetal well-being) or non-reactive (suggesting potential fetal compromise).
Choice D rationale
A positive non-stress test is also not a standard term used for NST interpretation. A positive result in fetal monitoring typically refers to a contraction stress test where late decelerations are observed, indicating potential uteroplacental insufficiency.
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