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
A reactive nonstress test demonstrates at least two accelerations in fetal heart rate, defined as an increase of 15 beats per minute above the baseline lasting for 15 seconds, within a 20-minute period. These accelerations indicate adequate fetal oxygenation and a healthy fetal autonomic nervous system response to movement.
Choice B rationale
Drawing blood to evaluate the baby's risk of genetic problems is typically performed through procedures like amniocentesis or chorionic villus sampling, not during a nonstress test. A nonstress test assesses fetal well-being based on heart rate patterns in response to fetal movement.
Choice C rationale
While fetal movement is an indicator of fetal well-being, the nonstress test specifically evaluates the fetal heart rate response to that movement. The number of movements within a specific time frame is a component of a biophysical profile, not the sole indicator in a nonstress test.
Choice D rationale
Ultrasound is used to visualize fetal anatomy and assess for congenital anomalies, which is a component of a fetal anatomy scan typically performed around 18-20 weeks of gestation. A nonstress test primarily monitors fetal heart rate and its reactivity.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
The nurse should first address the client’s calf findings followed by their stress about discharge.
Rationale for correct answers
Calf findings must be addressed first due to the risk of deep vein thrombosis (DVT), which is a known complication of cesarean delivery and postpartum immobility. The presence of unilateral calf edema (3 cm greater than the right) and tenderness, combined with an elevated D-dimer, strongly suggests a thrombotic process requiring urgent evaluation. If DVT is confirmed, anticoagulation therapy should be initiated promptly to prevent progression to pulmonary embolism.
Stress about discharge should be the second priority, as emotional concerns can affect adherence to postpartum care instructions. Addressing anxiety about recovery, follow-up visits, and newborn care can improve the client’s overall well-being and readiness for discharge.
Rationale for incorrect Response 1 options
- Breast engorgement: Although uncomfortable, this is a transient issue that can be managed with cold compresses and supportive bras. It does not pose an immediate health risk.
- Constipation: Postpartum bowel irregularities are expected after cesarean delivery; stool softeners and hydration can alleviate symptoms without urgency.
- Surgical incision pain: Rated only 2/10, indicating mild pain that does not require immediate intervention beyond routine analgesia.
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