A nurse is reviewing the history of a client who is pregnant.
Which of the following clinical data indicates the client is at risk for preterm delivery?
Previous delivery at 37 weeks gestation
Previous delivery of a newborn weighing 2.5 kg (5.5 lb)
Previous reactive non-stress test
Previous cervical cerclage
The Correct Answer is D
Choice A rationale
A previous delivery at 37 weeks gestation does not necessarily indicate a risk for preterm delivery. Preterm delivery is defined as delivery before 37 weeks of gestation.
Choice B rationale
A previous delivery of a newborn weighing 2.5 kg (5.5 lb) does not indicate a risk for preterm delivery. Low birth weight can be a result of preterm delivery, but it can also be due to other factors such as intrauterine growth restriction.
Choice C rationale
A previous reactive non-stress test does not indicate a risk for preterm delivery. A reactive non-stress test is a positive sign of fetal well-being.
Choice D rationale
A previous cervical cerclage indicates a risk for preterm delivery. Cervical cerclage is a procedure performed to prevent preterm birth in women with a history of preterm birth and who have a short cervix.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While applying a spermicidal cream or jelly to the diaphragm is recommended to increase its effectiveness, the use of a vaginal lubricant is not typically recommended.
Choice B rationale
Washing the diaphragm with mild soap and warm water is recommended after each use. However, using detergent soap may cause irritation and is not typically recommended.
Choice C rationale
The diaphragm can be inserted up to 6 hours before intercourse. This allows for flexibility and spontaneity.
Choice D rationale
The diaphragm should be left in place for at least 6 hours after intercourse, not 2 to 4 hours. This is to ensure that all sperm are killed by the spermicide.
Correct Answer is C
Explanation
Choice A rationale
A urinary output of 300 ml in 8 hours is within the normal range for a postpartum patient. The average urinary output is about 30 ml/hour.
Choice B rationale
Lochia rubra is a normal finding in the immediate postpartum period. It is the initial vaginal discharge after childbirth, which is red because it contains a large amount of blood. Changing perineal pads every 3 hours is considered normal.
Choice C rationale
A patient who is receiving magnesium sulfate and has absent deep tendon reflexes is experiencing magnesium toxicity. This is a serious condition that can lead to respiratory depression and cardiac arrest. The healthcare provider should be notified immediately.
Choice D rationale
Abdominal cramping during breastfeeding is a normal finding. During breastfeeding, the hormone oxytocin is released which can cause uterine contractions and lead to cramping.
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