Pre-term Labor > Maternal & Newborn
Exam Review
Assessment
Total Questions : 15
Showing 15 questions, Sign in for moreA nurse is assessing a pregnant client at 28 weeks of gestation.
Which finding should the nurse prioritize as a potential sign of pre-term labor?
Explanation
Mild lower abdominal cramping is a sign of preterm laborand should be prioritized as a potential complication.Preterm labor occurs when regular contractions begin to open your cervix before 37 weeks of pregnancy.
A full-term pregnancy should last about 40 weeks.
Choice B is wrong because a change in vaginal discharge color is not a specific sign of preterm labor.
It could be due to other factors such as infection or normal hormonal changes.
Choice C is wrong because a brief episode of low back pain is not a sign of preterm labor.
It could be due to posture, muscle strain or other causes.
Choice D is wrong because occasional fetal hiccups are not a sign of preterm labor.
They are normal movements of the fetus and do not indicate any distress or danger.
A nurse is performing a physical examination on a client who is at 30 weeks of gestation and has pre-term labor.
Which of the following findings indicates fetal distress?
Explanation
Fetal heart rate decelerations indicate fetal distress because they reflect a decrease in blood flow or oxygen to the fetus.
Choice A is wrong because a fetal heart rate of 150/min is within the normal range of 110-160 bpm.Choice B is wrong because a fetal heart rate variability of 10/min is considered moderate and reassuring.Choice D is wrong because fetal heart rate accelerations are a sign of fetal well-being and indicate that the fetus is responding to stimuli.
A nurse is performing a speculum examination on a client who is at 26 weeks of gestation and has pre-term labor.
Which of the following findings indicates a positive FFN test?
Explanation
Bluish-white secretions.
This indicates a positive FFN test, which means that the fetal fibronectin protein has been released into the cervical secretions.Fetal fibronectin is a protein that helps keep the amniotic sac attached to the lining of the uterus.A positive FFN test means that there is a higher risk of preterm labor.
Choice A is wrong because yellow-green discharge could indicate an infection, not preterm labor.
Choice B is wrong because bloody show is a sign of cervical dilation, not preterm labor.
Choice C is wrong because sticky mucus plug is a normal part of pregnancy, not preterm labor.
A negative FFN test means that there is a less than 1% chance of preterm labor within the next 2 weeks.The FFN test is used to rule out preterm labor and avoid unnecessary treatments.It is approved for use in women with symptoms of preterm labor who are 24 to 35 weeks pregnant.
A nurse is assessing a client for pre-term labor.
Which of the following assessments should the nurse prioritize?
Explanation
Performing a speculum examination of the vagina and cervix.
This is because a speculum examination can help determine the presence of cervical dilation, effacement, or infection, which are signs of pre-term labor.
A speculum examination can also detect the presence of fetal fibronectin, which is a protein that indicates an increased risk of pre-term delivery.
Choice A is wrong because obtaining a detailed history of previous pregnancies is not a priority assessment for pre-term labor.
While it can provide some information about the client’s risk factors, it does not indicate the current status of the pregnancy or the cervix.
Choice B is wrong because checking the fetal heart rate and activity is not a priority assessment for pre-term labor.
While it can provide some information about the fetal well-being, it does not indicate the presence or absence of contractions or cervical changes.
Choice D is wrong because performing laboratory tests, such as urine culture, is not a priority assessment for pre-term labor.
While it can help identify possible infections that may contribute to pre-term labor, it does not provide immediate results or indicate the current status of the cervix.
A nurse is performing a physical examination on a client suspected of pre-term labor.
Which assessment finding should the nurse report immediately?
Explanation
A positive fetal fibronectin test (FFN) indicates that the fetal membrane has been disrupted and labor may occur within the next 7 to 14 days.
This is a sign of preterm labor that should be reported immediately.
Choice A is wrong because elevated blood glucose level is not a sign of preterm labor, but a possible complication of gestational diabetes.
Choice B is wrong because thinning of the cervix (also called effacement) is a normal process that occurs during late pregnancy and labor.
It does not necessarily indicate preterm labor.
Choice D is wrong because abdominal tenderness is not a specific sign of preterm labor.
It could be caused by other factors such as constipation, gas, or stretching of the ligaments.
Some of the signs and symptoms of preterm labor include:
• Regular or frequent sensations of abdominal tightening (contractions) every 10 minutes or more often
• Change in vaginal discharge (leaking fluid or bleeding from the vagina)
• Feeling of pressure in the pelvis (hip) area
• Low, dull backache
• Cramps that feel like menstrual cramps
• Abdominal cramps with or without diarrhea
A nurse is caring for a client in pre-term labor.
Which intervention should the nurse prioritize to improve blood flow to the placenta and fetus?
Explanation
The correct answer is choice B. Administering tocolytics.Tocolytics are drugs that inhibit uterine contractions and can delay preterm labor for a short time.This can allow time for the administration of antenatal corticosteroids and transfer to a tertiary care facility if necessary.
Choice A is wrong because administering intravenous fluids does not improve blood flow to the placenta and fetus.It may also increase the risk of pulmonary edema in women with preterm labor.
Choice C is wrong because administering corticosteroids does not improve blood flow to the placenta and fetus.Corticosteroids are given to enhance fetal lung maturity and reduce the risk of neonatal complications such as respiratory distress syndrome, intracranial hemorrhage, and necrotizing enterocolitis.
However, they do not stop preterm labor.
Choice D is wrong because providing emotional support does not improve blood flow to the placenta and fetus.Emotional support is important for women with preterm labor, but it is not a priority intervention to prevent fetal hypoxia or acidosis.
A client at 28 weeks of gestation is experiencing pre-term labor.
Which intervention should the nurse anticipate to enhance fetal lung maturity?
Explanation
Administering corticosteroids.Corticosteroids are drugs that can speed up the development of the baby’s lungs and reduce the risk of respiratory distress syndrome and other complications of preterm birth.They are usually given to pregnant women who are at risk of preterm delivery between 24 0/7 weeks and 33 6/7 weeks of gestation.
Choice A is wrong because administering intravenous fluids does not enhance fetal lung maturity.
It may be used to treat dehydration or prevent hypotension, but it has no effect on the baby’s lungs.
Choice B is wrong because administering tocolytics does not enhance fetal lung maturity.
Tocolytics are drugs that can delay preterm labor for a short time, but they do not improve the baby’s lung function.
Choice D is wrong because providing emotional support does not enhance fetal lung maturity.
It may help the mother cope with stress and anxiety, but it does not affect the baby’s lungs.
Fetal lung maturity is the condition of the baby’s lungs being able to breathe normally after birth.It involves several developmental processes, such as the formation of alveoli, bronchi, and surfactant.
Fetal lungs are usually mature by 36 weeks of gestation, but some babies may need steroids to speed up lung development if they are at risk of preterm birth.
A nurse is monitoring a client in pre-term labor for signs of fetal lung maturity enhancement.
Which medication should the nurse anticipate administering?
Explanation
Betamethasone is a corticosteroid that can be given to pregnant women who are at risk of preterm labor to enhance fetal lung maturity and reduce the risk of respiratory distress syndrome in the newborn.
Betamethasone stimulates the production of surfactant, a substance that helps the lungs expand and prevents them from collapsing.
Choice A is wrong because magnesium sulfate is used to prevent seizures in women with preeclampsia or eclampsia, not to enhance fetal lung maturity.
Choice B is wrong because nifedipine is a calcium channel blocker that can be used to relax the uterine muscles and inhibit contractions in preterm labor, but it does not affect fetal lung development.
Choice D is wrong because ampicillin is an antibiotic that can be used to treat infections that may cause preterm labor, such as chorioamnionitis or group B streptococcus, but it does not have any direct effect on fetal lung maturation.
A client at 32 weeks of gestation is diagnosed with pre-term labor.
Which intervention should the nurse prioritize to reduce uterine activity?
Explanation
Administering tocolytics.Tocolytics are drugs that inhibit uterine contractions and can delay preterm labor for a short time.This can allow time for the administration of corticosteroids and transfer to a tertiary care facility if necessary.
Choice A is wrong because administering intravenous fluids does not reduce uterine activity.It may be used to correct dehydration or electrolyte imbalance, which can be risk factors for preterm labor.
Choice C is wrong because administering corticosteroids does not reduce uterine activity.It may be used to enhance fetal lung maturity and reduce the risk of neonatal complications such as respiratory distress syndrome, intracranial hemorrhage, and necrotizing enterocolitis.
Choice D is wrong because administering antibiotics does not reduce uterine activity.It may be used to treat infections that can trigger preterm labor, such as bacterial vaginosis or chorioamnionitis.
A nurse is caring for a client in pre-term labor and suspects an infection.
Which assessment finding would support this suspicion?
Explanation
A decrease in fetal heart rate can indicate fetal distress due to infection, hypoxia, or cord compression.
Normal fetal heart rate is between 110 and 160 beats per minute.
Choice B. Increased uterine contractions is wrong because it is a normal sign of pre-term labor and does not necessarily indicate infection.
Choice C. Decreased fluid intake is wrong because it is not a specific sign of infection and can have other causes such as nausea, vomiting, or decreased thirst.
Choice D. Decreased cervical changes is wrong because it is also not a specific sign of infection and can indicate ineffective contractions or cervical incompetence.
A client with pre-term labor is at 28 weeks of gestation.
Which intervention should the nurse prioritize to monitor fetal well-being?
Explanation
Monitoring cervical changes.
This is because cervical changes indicate the progress of labor and the risk of preterm delivery.
Preterm labor is defined as regular uterine contractions with cervical dilation and effacement before 37 weeks of gestation.
The nurse should assess the cervical length, dilation, effacement, and position frequently to determine the need for interventions to stop or delay labor.
Choice A is wrong because monitoring vital signs is not specific to fetal well-being.
Vital signs can reflect maternal health, infection, or complications, but they do not directly measure fetal status.
Choice C is wrong because monitoring fluid intake and output is not specific to fetal well-being.
Fluid balance can affect maternal hydration, electrolytes, and blood pressure, but it does not directly measure fetal status.
Choice D is wrong because monitoring maternal preference is not specific to fetal well-being.
Maternal preference can affect the comfort, satisfaction, and coping of the mother, but it does not directly measure fetal status.
A nurse is caring for a client who has preterm labor.
Which manifestation should the nurse identify as a complication of preterm labor?
Explanation
Haemorrhage due to placental abruption.
Placental abruption is a serious complication of preterm labor that occurs when the placenta separates from the wall of the uterus before delivery.This can cause heavy bleeding and endanger the life of both the mother and the baby.
Choice A is wrong because increased fetal movement is not a complication of preterm labor.In fact, decreased fetal movement may indicate fetal distress.
Choice B is wrong because decreased uterine contractions are not a complication of preterm labor.Preterm labor is defined as regular contractions that result in the opening of the cervix before 37 weeks of pregnancy.
Choice D is wrong because increased cervical dilation is not a complication of preterm labor, but a sign of it.Cervical dilation indicates that the cervix is preparing for delivery and may lead to preterm birth.
A nurse is caring for a newborn who was born prematurely.
Which finding should the nurse report as a potential complication of prematurity?
Explanation
Hypoglycemia due to low glycogen stores.
Premature newborns have low glycogen stores and are at risk of developing hypoglycemia, which can cause seizures, brain damage, or death.
The nurse should monitor the blood glucose levels of the newborn and report any signs of hypoglycemia, such as jitteriness, lethargy, poor feeding, or temperature instability.
Choice A is wrong because increased bilirubin levels, not decreased, are a potential complication of prematurity.
Bilirubin is a waste product of red blood cell breakdown that can accumulate in the blood and cause jaundice, a yellowing of the skin and eyes.
Premature newborns have immature livers that cannot process bilirubin effectively and may need phototherapy to reduce the levels.
Choice B is wrong because decreased fat stores, not increased, are a potential complication of prematurity.
Fat stores provide insulation and energy for the newborn and help maintain body temperature.
Premature newborns have less subcutaneous fat and are prone to heat loss and cold stress, which can affect their metabolism and oxygen consumption.
Choice D is wrong because absence of mature lung surfactant, not presence, is a potential complication of prematurity.
Surfactant is a substance that reduces the surface tension of the alveoli and prevents them from collapsing during expiration.
Premature newborns have insufficient surfactant production and may develop respiratory distress syndrome, which is characterized by tachypnea, grunting, retractions, and cyanosis.
A nurse is assessing a preterm newborn and notes the presence of retinopathy of prematurity (ROP).
Which intervention should the nurse anticipate in the plan of care?
Explanation
Scheduling regular eye examinations.
Retinopathy of prematurity (ROP) is an eye disease that can happen in babies who are premature or who weigh less than 3 pounds at birth.ROP happens when abnormal blood vessels grow in the retina, which can cause vision loss or blindness.
The best way to prevent and treat ROP is to monitor the retinal development and detect any signs of abnormal blood vessel growth early.This can be done by regular eye examinations by an ophthalmologist.Some babies with mild ROP may get better without treatment, but some may need laser treatment, eye injections, or surgery to stop the abnormal blood vessels and prevent retinal detachment.
Choice A is wrong because antibiotics are not used to treat ROP.
Antibiotics are used to treat infections, which are not the cause of ROP.
Choice B is wrong because phototherapy is not used to treat ROP.
Phototherapy is used to treat jaundice, which is a condition where the skin and eyes turn yellow due to high levels of bilirubin in the blood.
Jaundice is not related to ROP.
Choice C is wrong because surfactant is not used to treat ROP.
Surfactant is a substance that helps the lungs function properly by reducing the surface tension of the air sacs.
Surfactant may be given to premature babies who have respiratory distress syndrome, which is a lung problem that can affect their oxygen levels.However, surfactant does not directly affect the retina or the blood vessels in the eye.
A nurse is caring for a client who is at risk for developing intraventricular hemorrhage (IVH).
Which action should the nurse take to reduce the client's risk?
Explanation
Maintaining a neutral head position.This action can help reduce the client’s risk of intraventricular hemorrhage (IVH) by preventing fluctuations in intracranial pressure that could rupture blood vessels in the brain.
Choice A is wrong because encouraging early ambulation can increase the risk of IVH by causing changes in blood pressure and cerebral perfusion.
Choice B is wrong because administering medications to induce hypercoagulability can increase the risk of IVH by promoting thrombosis and impairing blood flow to the brain.
Choice C is wrong because monitoring the client’s blood glucose levels is not directly related to the prevention of IVH, although it may be important for other reasons such as avoiding hypoglycemia or hyperglycemia.
Sign Up or Login to view all the 15 Questions on this Exam
Join over 100,000+ nursing students using Nursingprepexams’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
