A nurse is caring for a pregnant client at 36 weeks of gestation who reports low back pain and pelvic pressure.

Which intervention should the nurse implement first?

Administer a dose of tocolytic medication

Encourage the client to rest in a side-lying position

Assess fetal heart rate using a Doppler device

Assess vaginal discharge for any change

Answer and Explanation

The Correct Answer is C

Assess fetal heart rate using a Doppler device.

This is because low back pain and pelvic pressure at 36 weeks of gestation may indicate preterm labor, which can affect the fetal well-being. Therefore, the nurse should assess the fetal heart rate as a priority to determine if the fetus is in distress or not.

Choice A is wrong because tocolytic medication is used to stop uterine contractions, not to relieve low back pain and pelvic pressure. Choice B is wrong because resting in a side-lying position may help with blood circulation and reduce supine hypotensive syndrome, but it does not address the possible cause of low back pain and pelvic pressure. Choice D is wrong because assessing vaginal discharge for any change may indicate infection, rupture of membranes, or cervical dilation, but it is not as urgent as assessing fetal heart rate.

Some interventions for preventing and treating low back pain and pelvic pressure during pregnancy include exercise, water-based exercise, acupuncture, osteomanipulative therapy, craniosacral therapy, and pelvic support belts.

However, these interventions should be discussed with the health care provider before starting them.

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Correct Answer is A

Explanation

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.

A. Encourage the parents to touch and talk to the infant through the incubator ports B. Limit the parents’ visitation time to prevent overstimulation of the infant C. Advise the parents to avoid eye contact with the infant until he is stable D. Restrict the parents from holding or feeding the infant until he is discharged.

Correct Answer is A

Explanation

Encouraging the parents to touch and talk to the infant through the incubator ports can promote bonding between the infant and the parents.Bonding is the intense attachment that develops between parents and their baby, and it is essential for the baby’s social and cognitive development.Touch and communication are some of the ways that babies bond with their parents.

Choice B is wrong because limiting the parents’ visitation time can disrupt the bonding process and make the parents feel less involved in their baby’s care.

Choice C is wrong because eye contact is another way of bonding with babies, and it can help them feel secure and loved.

Choice D is wrong because holding and feeding the infant are also important ways of bonding, and they should not be restricted unless medically necessary.

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A nurse is caring for a pregnant client at 36 weeks of gestation who reports low back pain and pelvic pressure. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A nurse is planning care for a pre-term infant who is in an incubator. Which of the following interventions should the nurse include to promote bonding between the infant and the parents?

Correct Answer is A

Explanation

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A nurse is monitoring a client who is receiving terbutaline for pre-term labor. Which of the following findings should the nurse report to the provider as a potential adverse effect of the medication?

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A nurse is caring for a pregnant client at 36 weeks of gestation who reports low back pain and pelvic pressure.

Which intervention should the nurse implement first?