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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Mild lower abdominal cramping is a sign of preterm laborand should be prioritized as a potential complication.Preterm labor occurs when regular contractions begin to open your cervix before 37 weeks of pregnancy.
A full-term pregnancy should last about 40 weeks.
Choice B is wrong because a change in vaginal discharge color is not a specific sign of preterm labor.
It could be due to other factors such as infection or normal hormonal changes.
Choice C is wrong because a brief episode of low back pain is not a sign of preterm labor.
It could be due to posture, muscle strain or other causes.
Choice D is wrong because occasional fetal hiccups are not a sign of preterm labor.
They are normal movements of the fetus and do not indicate any distress or danger.
Correct Answer is B
Explanation
Monitoring cervical changes.
This is because cervical changes indicate the progress of labor and the risk of preterm delivery.
Preterm labor is defined as regular uterine contractions with cervical dilation and effacement before 37 weeks of gestation.
The nurse should assess the cervical length, dilation, effacement, and position frequently to determine the need for interventions to stop or delay labor.
Choice A is wrong because monitoring vital signs is not specific to fetal well-being.
Vital signs can reflect maternal health, infection, or complications, but they do not directly measure fetal status.
Choice C is wrong because monitoring fluid intake and output is not specific to fetal well-being.
Fluid balance can affect maternal hydration, electrolytes, and blood pressure, but it does not directly measure fetal status.
Choice D is wrong because monitoring maternal preference is not specific to fetal well-being.
Maternal preference can affect the comfort, satisfaction, and coping of the mother, but it does not directly measure fetal status.
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