A nurse is reinforcing teaching about preterm labor with a client who is at 28 weeks of gestation.Which of the following statements by the client indicates an understanding of the teaching?
“I should expect to feel pain in my upper right abdomen if I’m having preterm labor.”.
“If I have contractions more often than every 10 minutes, I might be in preterm labor.”.
“I can take a daily iron supplement to prevent preterm labor.”.
“I might be experiencing preterm labor if walking stops my contractions.”.
The Correct Answer is B
Choice A rationale
Pain in the upper right abdomen is not a typical sign of preterm labor. Preterm labor symptoms include regular contractions, lower back pain, and pelvic pressure.
Choice B rationale
Contractions occurring more frequently than every 10 minutes can indicate preterm labor. Regular contractions are a key sign of preterm labor.
Choice C rationale
While iron supplements are important during pregnancy, they do not prevent preterm labor. Preterm labor is influenced by various factors, including infections and uterine abnormalities.
Choice D rationale
Walking typically does not stop contractions associated with preterm labor. In fact, activity can sometimes exacerbate contractions.
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Correct Answer is ["E","F"]
Explanation
Choice A rationale:
The head assessment finding is not mentioned as abnormal in the exhibits. The anterior fontanelle is soft and flat, which is a normal finding in newborns. This indicates that there is no increased intracranial pressure or dehydration. The head circumference and shape are also not noted to have any abnormalities, which suggests that the newborn’s head development is within normal limits.
Choice B rationale:
The glucose level is not provided in the exhibits. However, routine glucose monitoring is not typically required for healthy, term newborns unless they exhibit symptoms of hypoglycemia or have risk factors such as being large for gestational age, small for gestational age, or born to mothers with diabetes. Since the newborn is feeding well and has no signs of hypoglycemia, there is no immediate concern regarding glucose levels.
Choice C rationale:
The mucous membrane assessment shows that the mucous membranes are moist and pink, which is a normal finding. This indicates that the newborn is well-hydrated and has good perfusion. There are no signs of dehydration, pallor, or lesions in the oral cavity, which suggests that the newborn’s mucous membranes are healthy.
Choice D rationale:
The intake and output are adequate, as evidenced by the number of wet diapers and stools. The newborn has had six wet diapers and three stools in the past 24 hours, which is within the normal range for a healthy, breastfed newborn. This indicates that the newborn is receiving sufficient nutrition and is well-hydrated.
Choice E rationale:
The respiratory rate of 44/min is on the higher end of the normal range for newborns, which is typically 30-60 breaths per minute. However, it is important to monitor for any signs of respiratory distress or abnormalities, such as grunting, flaring, or retractions. Reporting this finding ensures that any potential issues are addressed promptly.
Choice F rationale:
The heart rate of 154/min is within the normal range for newborns, which is typically 120-160 beats per minute. However, it is on the higher end of the spectrum. Monitoring and reporting this finding is crucial to ensure that the newborn’s cardiovascular status remains stable and to rule out any underlying conditions that may require intervention.
Correct Answer is A
Explanation
Choice A rationale
Retained placental fragments are a significant risk factor for postpartum hemorrhage. If parts of the placenta remain attached to the uterine wall, it can prevent the uterus from contracting properly, leading to excessive bleeding.
Choice B rationale
Breech presentation is not a direct risk factor for postpartum hemorrhage. While it can complicate delivery, it does not directly cause hemorrhage.
Choice C rationale
Urinary tract infection is not a risk factor for postpartum hemorrhage. It can cause other complications but does not directly lead to hemorrhage.
Choice D rationale
Oligohydramnios, or low amniotic fluid, is not a risk factor for postpartum hemorrhage. It can cause complications during pregnancy but does not directly lead to hemorrhage.