A nurse on an antepartum unit is caring for a 28-year-old gravida 1 para 0 female client at 32 weeks of gestation.
Complete the following sentence by using the list of options. The nurse should identify that _______ are findings that require follow-up.
Contractions every 5 minutes
Fetal heart rate of 140/min
Clear mucus discharge
Closed cervix
The Correct Answer is A
The nurse should identify that contractions occurring every 5 minutes require follow-up for several reasons:
- Preterm Labor Risk: At 32 weeks of gestation, regular contractions every 5 minutes could indicate the onset of preterm labor. This is concerning because preterm labor can lead to preterm birth, which poses significant risks to the baby's health and development.
- Frequency and Intensity: These contractions are occurring frequently (every 5 minutes) and are described as stronger than usual Braxton Hicks contractions. This frequency and the strength of the contractions are unusual for Braxton Hicks, which are typically irregular and less intense.
- Effacement and Cervical Changes: Although the cervix is closed, it is 80% effaced. Effacement means the cervix is thinning, which, in combination with regular contractions, may indicate that the body is preparing for labor.
- Urinary Leakage: The client also reported urinary leakage earlier in the day, which could be a sign of ruptured membranes (water breaking). This, combined with regular contractions, increases the need for careful monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Irregular heartbeat (palpitations or arrhythmias) can indicate a serious cardiovascular side effect of nifedipine. It requires immediate medical attention as it could compromise maternal and fetal circulation.
Choice B rationale
Hair loss is not a known adverse effect of nifedipine and generally does not pose a significant health risk. It is more commonly associated with hormonal changes rather than medication side effects.
Choice C rationale
Increased salivation is not a common side effect of nifedipine. Nifedipine primarily affects the cardiovascular system rather than salivary glands.
Choice D rationale
Pause is not a recognized adverse effect related to nifedipine usage. The term itself is ambiguous and not typically associated with the pharmacological profile of nifedipine.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}
Explanation
Preterm Labor
Preterm labor refers to labor that begins before 37 weeks of gestation. The key findings associated with preterm labor are:
- Cervical effacement and dilation: The client is 100% effaced and 2 cm dilated.
- Regular uterine contractions: The client is experiencing contractions every 3 minutes, lasting 60 seconds.
- Bloody show: The presence of bloody mucus discharge is another sign of preterm labor.
- Low backache: The client reports cramping and low back pain.
Preterm Prelabor Rupture of Membranes (PPROM)
PPROM refers to the rupture of membranes before labor begins and before 37 weeks of gestation. The key findings associated with PPROM are:
- Vaginal discharge: The client reported urinary leakage earlier, which could be misinterpreted as amniotic fluid leakage. Clear mucus discharge can also be a sign of ruptured membranes.
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