A nurse on an antepartum unit is caring for a 28-year-old gravida 1 para 0 female client at 32 weeks of gestation.
Exhibit 1: History and Physical The client is 32 weeks pregnant and has been experiencing cramping and low back pain for the past 3 hours. She rates her pain as 2 on a scale of 0 to 10. She describes the pain as stronger than usual Braxton Hicks contractions and mentions having a little urinary leakage earlier in the day. She denies vaginal bleeding. The client decided to come in for evaluation at her doctor's advice.
Exhibit 2: Nurse's Notes 0900: The client reports cramping and low back pain started 3 hours ago. She rates the pain as 2 on a scale of 0 to 10. She feels the contractions are stronger than usual Braxton Hicks contractions. She mentions urinary leakage earlier today but denies any vaginal bleeding. The external fetal monitor shows contractions occurring every 5 minutes, lasting 30 seconds, and of moderate intensity. Fetal heart rate is 140/min. A vaginal exam reveals the cervix is closed and 80% effaced. No bleeding is noted, but there is clear mucus discharge on the exam glove.
Exhibit 3:
Vital Signs Heart rate: 80/min
Blood pressure: 120/80 mmHg
Respiratory rate: 18/min
Temperature: 36.8°C (98.2°F)
Oxygen saturation: 98%Exhibit 4:
Physical Examination Results
The client's abdomen is soft, non-tender, and the fundal height corresponds to the gestational age. No signs of vaginal bleeding are observed. Clear mucus discharge is noted on the exam glove. The cervix is closed and 80% effaced. The fetal heart rate is regular at 140/min. The client appears anxious but is in no acute distress. The fetal movements are felt and reported to be normal.
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
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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.
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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.
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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.
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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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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 D
Explanation
Choice A rationale
Elevating the head of the client’s bed is not indicated in this situation and does not address the issue of excessive bleeding postpartum.
Choice B rationale
Administering terbutaline, a medication used to manage preterm labor, is not relevant in the context of postpartum hemorrhage and excessive bleeding.
Choice C rationale
Initiating oxygen at 2 L/min via nasal cannula may help with oxygenation but does not address the primary issue of excessive postpartum bleeding.
Choice D rationale
Initiating an infusion of oxytocin is the correct action as it helps contract the uterus and reduce postpartum bleeding, making it a crucial step in managing this situation.