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
Methadone is often prescribed to pregnant women with opioid use disorder and is considered safe for breastfeeding. Breastfeeding can provide additional benefits such as bonding and transferring antibodies to the infant.
Choice B rationale
Methamphetamine use during pregnancy is linked to fetal growth restriction, preterm birth, and low birth weight, not fetal macrosomia (large body size).
Choice C rationale
Reducing environmental stimuli is essential for neonates exposed to substances in utero. Increased stimuli can overwhelm their underdeveloped nervous systems, leading to stress and adverse outcomes.
Choice D rationale
Fetal alcohol syndrome is characterized by growth deficiencies, facial abnormalities, and central nervous system dysfunction. An increased head circumference is not a typical feature; rather, microcephaly (small head circumference) is more common.
Correct Answer is D
Explanation
Choice A rationale
Leukorrhea is a common and normal occurrence in pregnancy due to increased estrogen production and greater blood flow to the vaginal area. It is usually a thin, white discharge and not a cause for concern unless accompanied by itching, burning, or an unusual odor.
Choice B rationale
Excessive salivation, also known as ptyalism, can occur during pregnancy, particularly in the first trimester. It is linked to hormonal changes and is not typically harmful, though it may be uncomfortable for the patient.
Choice C rationale
Darkening of the skin on the face, known as melasma or chloasma, is common during pregnancy and is due to increased pigmentation from hormonal changes. It typically resolves postpartum and is not harmful.
Choice D rationale
Epigastric pain in a pregnant client at 33 weeks gestation can be a sign of preeclampsia, a serious condition characterized by high blood pressure and damage to other organs. It requires immediate medical attention to prevent complications for both the mother and baby.
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