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 A
Explanation
Assess the client’s vital signs.
The nurse should first assess the client’s vital signs to determine the severity of the situation and identify any signs of infection, bleeding, or shock.
The nurse should also monitor the fetal heart rate to assess fetal well-being.
Choice B is wrong because a sterile vaginal exam is not indicated for a client who reports lower abdominal cramping and may increase the risk of infection or rupture of membranes.
Choice C is wrong because administering tocolytic medication is not the first action the nurse should take.
Tocolytic medication may be used to inhibit uterine contractions and prolong pregnancy, but only after assessing the client’s and fetus’s condition and obtaining a prescription from the provider.
Choice D is wrong because monitoring the fetal heart rate is not the first action the nurse should take.
Monitoring the fetal heart rate is important to assess fetal well-being, but it does not take priority over assessing the client’s vital signs.
Correct Answer is B
Explanation
Blood pressure of 150/90 mmHg.This is because terbutaline can causeelevated blood pressureas a side effect.
The nurse should report this finding to the provider as it may indicate hypertension or a hypertensive crisis.
Choice A is wrong because a heart rate of 110/min is not abnormal for a person who has received terbutaline.Terbutaline can causefast or pounding heartbeatsas a common side effect.
Choice C is wrong because a blood glucose of 90 mg/dL is within the normal range of 70-130 mg/dL before meals.Terbutaline can causetransient hyperglycemia(high blood sugar) as a serious side effect, but this is not the case here.
Choice D is wrong because a temperature of 37°C (98.6°F) is normal for a human being.Terbutaline does not cause fever or hypothermia as a side effect.
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