A nurse is conducting discharge teaching with a pregnant client at 32 weeks' gestation admitted to the facility with preterm labor that has been arrested.
The nurse determines that the teaching was successful based on which client statement?
It's safe for me to do any type of activity at home.
I need to remain on strict bed rest when I go home.
My contractions will be a lot stronger than the ones I have now when I go into labor.
I need to do a fetal kick count each day while at home.
The Correct Answer is D
Choice A rationale
Unrestricted activity is generally not safe after arrested preterm labor, as physical exertion can potentially stimulate uterine activity, risking recurrence of contractions and possible delivery. While strict bed rest is often not necessary, modified activity and pelvic rest are commonly advised to decrease physical stress and uterine irritability, thus promoting maintenance of the pregnancy until term.
Choice B rationale
Strict bed rest is generally not recommended for a client at home after arrested preterm labor, as prolonged immobility can lead to complications such as venous thromboembolism (VTE), muscle atrophy, and deconditioning. The standard recommendation is often modified rest or pelvic rest, restricting strenuous activities but allowing limited, necessary movement to maintain overall health and circulation.
Choice C rationale
The strength of future labor contractions is determined by complex physiological processes, including oxytocin receptor density and myometrial response, and is not necessarily correlated with the intensity of previous preterm contractions. Preterm contractions are often less efficient in cervical dilation due to gestational immaturity, and later, term contractions will be physiologically sufficient for delivery.
Choice D rationale
Fetal kick counts are a simple, non-invasive method for the client to assess fetal well-being and oxygenation at home. A decrease in fetal movement can be an early indicator of fetal distress or compromise, prompting the client to seek immediate medical evaluation. This self-monitoring technique is a crucial component of discharge teaching after a preterm labor scare.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["60"]
Explanation
Step 1 is: Convert the ordered rate from mU/min to mU/hr. 20 mU/min× 60 min/hr = 1200 mU/hr.
Step 2 is: Convert the available concentration from units/mL to mU/mL. 20 units = 20,000 mU (since 1 unit = 1000 mU). The concentration is 20,000 mU÷ 1000 mL = 20 mU/mL.
Step 3 is: Calculate the infusion rate in mL/hr. 1200 mU/hr÷ (20 mU/mL). 60 mL/hr. The oxytocin will infuse at 60 mL/hr.
Correct Answer is B
Explanation
Choice A rationale
Amniotomy, the artificial rupture of membranes, is typically performed to induce or augment labor, especially if the membranes are intact and labor is progressing slowly. However, it carries risks such as cord prolapse, especially when the presenting part is floating (station -3 or higher), as noted, making this intervention inappropriate and potentially hazardous currently.
Choice B rationale
Early decelerations are a benign finding caused by transient fetal head compression during a contraction, mirroring the contraction shape. A floating presenting part (station greater than or equal to -3) signifies the fetal head has not yet entered the pelvic inlet, which is characteristic of the second stage of labor, or the active phase of the first stage of labor.
Choice C rationale
Early decelerations are considered a reassuring fetal heart rate pattern. Fetal distress is indicated by late or severe variable decelerations, persistent bradycardia, or absent variability, which are not present here. The FHR of 140 beats/min is within the normal range (110–160 beats/min), indicating adequate oxygenation.
Choice D rationale
A Cesarean birth is not immediately necessary. The findings—reassuring FHR pattern with early decelerations and a normal FHR of 140 beats/min—do not indicate fetal distress or an immediate maternal or fetal emergency that would necessitate urgent surgical intervention.
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