A nurse is providing discharge instructions to a client who had pre-term labor at 32 weeks of gestation and was prescribed bed rest at home.
Which of the following statements by the client indicates an understanding of the teaching?
“I will drink at least eight glasses of water every day.”
“I will lie on my back with a pillow under my knees.”
“I will avoid sexual intercourse until I reach term.”
“I will call my doctor if I have more than four contractions in an hour.”
The Correct Answer is D
“I will call my doctor if I have more than four contractions in an hour.” This statement indicates that the client understands the signs of preterm labor and when to seek medical attention. Preterm labor is defined as having regular contractions and cervical changes before 37 weeks of gestation. More than four contractions in an hour may indicate that preterm labor is occurring and requires prompt evaluation.
Choice A is wrong because drinking at least eight glasses of water every day is not a specific instruction for preventing preterm labor. However, dehydration can trigger contractions and should be avoided.
Choice B is wrong because lying on the back with a pillow under the knees can reduce blood flow to the uterus and the baby. This position can also increase the risk of blood clots in the legs. A better position is lying on the left side, which improves circulation and reduces pressure on the cervix.
Choice C is wrong because avoiding sexual intercourse until reaching term is not necessary for most women with a history of preterm labor. Sexual activity does not cause preterm labor or premature rupture of membranes (PROM). However, some women may be advised to abstain from sex if they have certain conditions, such as placenta previa or a short cervix.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Tachycardia.
Terbutaline is a medication that can be used to stop or delay preterm labor by relaxing the uterine muscles.However, it can also cause serious side effects for both the mother and the baby.One of the most common side effects of terbutaline is tachycardia, which means a fast or irregular heartbeat.This can lead to chest pain, palpitations, shortness of breath, and even cardiac arrhythmias or ischemia.
Therefore, the nurse should monitor the mother’s heart rate and rhythm closely when administering terbutaline.
Choice A is wrong because terbutaline does not cause hypotension, which means low blood pressure.In fact, terbutaline can increase blood pressure by constricting blood vessels.
Choice C is wrong because terbutaline does not cause hyperglycemia, which means high blood sugar.However, terbutaline can interfere with insulin secretion and glucose metabolism in some cases, especially in diabetic mothers.
Therefore, the nurse should monitor the mother’s blood sugar levels when administering terbutaline.
Choice D is wrong because terbutaline does not cause hypokalemia, which means low potassium levels in the blood.However, terbutaline can cause a temporary increase in potassium levels in the baby, which can affect the baby’s heart function.
Therefore, the nurse should monitor the baby’s heart rate and rhythm when administering terbutaline.
Normal ranges for heart rate are 60 to 100 beats per minute for adults and 120 to 160 beats per minute for fetuses.
Normal ranges for blood pressure aretypically between 90/60 mmHg and 120/80 mmHg.
Correct Answer is C
Explanation
White blood cell count 25,000/mm3.
This indicates a potential complication of necrotizing enterocolitis (NEC), which is the death of intestinal tissue in premature or sick newborns.A high white blood cell count can be a sign of infection or inflammation in the bowel, which are common features of NEC.
Choice A is wrong because hematocrit 45% is within the normal range for newborns.
Hematocrit measures the percentage of red blood cells in the blood.
A low hematocrit can indicate blood loss or anemia, which can be complications of NEC, but a normal hematocrit does not rule out NEC.
Choice B is wrong because platelets 150,000/mm3 is also within the normal range for newborns.
Platelets are cells that help the blood clot.A low platelet count can indicate a consumption coagulopathy, which is a bleeding disorder that can occur in severe cases of NEC.
However, a normal platelet count does not exclude NEC.
Choice D is wrong because blood glucose 80 mg/dL is also within the normal range for newborns.
Blood glucose measures the amount of sugar in the blood.
A low blood glucose can indicate hypoglycemia, which can be caused by sepsis or other conditions that mimic NEC, but a normal blood glucose does not eliminate NEC.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.