A nurse is performing a physical examination on a client suspected of pre-term labor.

Which assessment finding should the nurse report immediately?

Elevated blood glucose level

Thinning of the cervix

Positive fetal fibronectin test (FFN)

Abdominal tenderness

Answer and Explanation

The Correct Answer is C

A positive fetal fibronectin test (FFN) indicates that the fetal membrane has been disrupted and labor may occur within the next 7 to 14 days.

This is a sign of preterm labor that should be reported immediately.

Choice A is wrong because elevated blood glucose level is not a sign of preterm labor, but a possible complication of gestational diabetes.

Choice B is wrong because thinning of the cervix (also called effacement) is a normal process that occurs during late pregnancy and labor.

It does not necessarily indicate preterm labor.

Choice D is wrong because abdominal tenderness is not a specific sign of preterm labor.

It could be caused by other factors such as constipation, gas, or stretching of the ligaments.

Some of the signs and symptoms of preterm labor include:

• Regular or frequent sensations of abdominal tightening (contractions) every 10 minutes or more often

• Change in vaginal discharge (leaking fluid or bleeding from the vagina)

• Feeling of pressure in the pelvis (hip) area

• Low, dull backache

• Cramps that feel like menstrual cramps

• Abdominal cramps with or without diarrhea

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Correct Answer is C

Explanation

Haemorrhage due to placental abruption.

Placental abruption is a serious complication of preterm labor that occurs when the placenta separates from the wall of the uterus before delivery.This can cause heavy bleeding and endanger the life of both the mother and the baby.

Choice A is wrong because increased fetal movement is not a complication of preterm labor.In fact, decreased fetal movement may indicate fetal distress.

Choice B is wrong because decreased uterine contractions are not a complication of preterm labor.Preterm labor is defined as regular contractions that result in the opening of the cervix before 37 weeks of pregnancy.

Choice D is wrong because increased cervical dilation is not a complication of preterm labor, but a sign of it.Cervical dilation indicates that the cervix is preparing for delivery and may lead to preterm birth.

A. Administering antibiotics to treat infection B. Providing phototherapy to treat jaundice C. Administering surfactant to improve lung function D. Scheduling regular eye examinations

Correct Answer is D

Explanation

Scheduling regular eye examinations.

Retinopathy of prematurity (ROP) is an eye disease that can happen in babies who are premature or who weigh less than 3 pounds at birth.ROP happens when abnormal blood vessels grow in the retina, which can cause vision loss or blindness.

The best way to prevent and treat ROP is to monitor the retinal development and detect any signs of abnormal blood vessel growth early.This can be done by regular eye examinations by an ophthalmologist.Some babies with mild ROP may get better without treatment, but some may need laser treatment, eye injections, or surgery to stop the abnormal blood vessels and prevent retinal detachment.

Choice A is wrong because antibiotics are not used to treat ROP.

Antibiotics are used to treat infections, which are not the cause of ROP.

Choice B is wrong because phototherapy is not used to treat ROP.

Phototherapy is used to treat jaundice, which is a condition where the skin and eyes turn yellow due to high levels of bilirubin in the blood.

Jaundice is not related to ROP.

Choice C is wrong because surfactant is not used to treat ROP.

Surfactant is a substance that helps the lungs function properly by reducing the surface tension of the air sacs.

Surfactant may be given to premature babies who have respiratory distress syndrome, which is a lung problem that can affect their oxygen levels.However, surfactant does not directly affect the retina or the blood vessels in the eye.

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A nurse is performing a physical examination on a client suspected of pre-term labor. Which assessment finding should the nurse report immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has preterm labor. Which manifestation should the nurse identify as a complication of preterm labor?

Correct Answer is C

Explanation

A nurse is assessing a preterm newborn and notes the presence of retinopathy of prematurity (ROP). Which intervention should the nurse anticipate in the plan of care?

Correct Answer is D

Explanation

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A nurse is performing a physical examination on a client suspected of pre-term labor.

Which assessment finding should the nurse report immediately?