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.
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Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Hypertension is not a characteristic finding of hyperemesis gravidarum, which primarily affects fluid balance and nutritional status.
Choice B rationale
Dry mucous membranes are a sign of dehydration, commonly associated with hyperemesis gravidarum due to excessive vomiting.
Choice C rationale
Tachycardia can result from dehydration and electrolyte imbalances seen in hyperemesis gravidarum.
Choice D rationale
Poor skin turgor indicates dehydration, a common symptom of hyperemesis gravidarum.
Choice E rationale
Polyuria is not typical in hyperemesis gravidarum; the condition usually leads to dehydration, reducing urine output.
Correct Answer is C
Explanation
Choice A rationale
A positive finding for galactosemia, not PKU, indicates the inability to metabolize galactose. Galactosemia is a different metabolic disorder that requires a separate dietary intervention.
Choice B rationale
A positive PKU test does not indicate slow metabolism. Instead, it signifies the inability to metabolize phenylalanine, an amino acid.
Choice C rationale
Phenylketonuria (PKU) is a genetic disorder that leads to the inability to break down the amino acid phenylalanine. Without proper management, it can accumulate in the body and cause brain damage and other health issues.
Choice D rationale
A positive PKU test is not directly linked to an increased risk for neurological anomalies in general. The specific issue in PKU is the inability to metabolize certain amino acids, primarily phenylalanine, which can cause neurological damage if untreated. .
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