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Early Onset of Labor – ATI CH 10

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Early Onset of Labor
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Preterm labor, premature rupture of membranes, and preterm premature rupture of membranes
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Preterm labor
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uterine contractions and cervical changes that occur between 20 and 37 weeks of gestation.
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Name 5 risk factors that are associated with preterm labor:
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● Infections of the urinary tract, vagina, or chorioamnionitis (infection of the amniotic sac) ● Previous preterm birth ● Multifetal pregnancy ● Hydramnios (excessive amniotic fluid) ● Age below 17 or above 35
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Name another 5 risk factors associated with preterm labor:
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● Low socioeconomic status ● Smoking ● Substance use ● Domestic violence ● History of multiple miscarriages or abortions
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Name an additional 7 risk factors associated with preterm labor:
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● Diabetes mellitus or hypertension ● Lack of prenatal care ● Recurrent premature dilation of the cervix ● Placenta previa or abruptio placentae ● Preterm premature rupture of membranes ● Short interval between pregnancies ● Uterine abnormalities
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What kind of subjective assessment data can be observed with preterm labor?
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β—― Persistent low backache β—― Pressure in the pelvis and cramping β—― Gastrointestinal cramping, sometimes with diarrhea β—― Urinary frequency β—― Vaginal discharge
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What kind of objective assessment data would be observed with preterm labor?
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β–  Increase, change, or blood in vaginal discharge β–  Change in cervical dilation β–  Regular uterine contractions with a frequency of every 10 min or greater, lasting 1 hr or longer β–  Premature rupture of membranes
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What laboratory tests are associated with preterm labor?
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β–  Fetal fibronectin β–  Cervical cultures β–  CBC β–  Urinalysis
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What are the common diagnostic procedures for a woman at risk for preterm labor?
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Fetal fibronectin swab Ultrasound HUAM Cervical Cultures Biophysical profile
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Explain the significance of the following diagnostic procedures to preterm labor: Fetal fibronectin swab Ultrasound
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β–  Obtain swab of vaginal secretions for fetal fibronectin between 24 and 34 weeks of gestation. This protein can be found in the vaginal secretions when the fetal membrane integrity is lost. This test is used to determine preterm labor. β–  Measure endocervical length with an ultrasound to assess for a shortened cervix, which is suggested in certain studies to precede preterm labor.
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Explain the significance of the following diagnostic procedures to preterm labor: HUAM Cervical Cultures Biophysical profile
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β–  Use home uterine activity monitoring (HUAM), which is a uterine contraction monitor that can be used by the client at home. HUAM is not considered to be effective in preventing preterm labor. β–  Obtain cervical cultures to detect if there is a presence of infectious organisms. Culture and sensitivity results guide prescription of an appropriate antibiotic, if indicated. β–  Perform a biophysical profile and/or a nonstress test to provide information about the fetal well-being.
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What is the main nursing care objective in the management of preterm labor?
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stopping uterine contractions
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What nursing care actions would the nurse implement when managing preterm labor?
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β–  Activity restriction β–  Ensuring hydration β–  Identifying and treating an infection β–  Chorioamnionitis should be suspected with the occurrence of elevated temperature and tachycardia. β–  Monitor FHR and contraction pattern.
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Explain the significance of advising a woman to restrict activity for the management of preterm labor:
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β–  Activity restriction ☐ Instruct the client on ways to modify her environment to allow for modified bed rest, yet have the ability to fulfill role responsibilities. Strict bed rest has been found to have adverse effects. ☐ Encourage the client to rest in the left lateral position to increase blood flow to the uterus and decrease uterine activity. ☐ Tell the client to avoid sexual intercourse.
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Why is it important to ensure that a woman facing preterm is adequately hydrated?
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Dehydration stimulates the pituitary gland to secrete an antidiuretic hormone and oxytocin. Preventing dehydration prevents the release of oxytocin, which stimulates uterine contractions.
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When managing preterm labor, why is it important to monitor FHR and contraction pattern?
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Fetal tachycardia, a prolonged increase in the FHR greater than 160/min may indicate infection, which is frequently associated with preterm labor.
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What is important for the nurse to consider regarding infection and the management of preterm labor?
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β–  Identifying and treating an infection ☐ Have the client report any vaginal discharge, noting color, consistency, and odor. ☐ Monitor vital signs and temperature. β–  Chorioamnionitis should be suspected with the occurrence of elevated temperature and tachycardia.
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Which medications are associated with preterm labor?
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β—― Nifedipine (Procardia, Adalat) β—― Magnesium sulfate β—― Indomethacin (Indocin) β—― Betamethasone (Celestone)
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Why is Nifedipine (Procardia, Adalat) used in the management of preterm labor?
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β—― Nifedipine (Procardia, Adalat) ☐ calcium channel blocker that is used to suppress contractions by inhibiting calcium from entering smooth muscles.
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Why is Magnesium sulfate used in the management of preterm labor?
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β—― Magnesium sulfate ☐ a commonly used tocolytic that relaxes the smooth muscle of the uterus and thus inhibits uterine activity by suppressing contractions.
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Why is Indomethacin (Indocin) used in the management of preterm labor?
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β—― Indomethacin (Indocin) ☐ nonsteroidal anti-inflammatory drug (NSAID) that suppresses preterm labor by blocking the production of prostaglandins. This inhibition of prostaglandins suppresses uterine contractions.
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Why is Betamethasone (Celestone) used in the management of preterm labor?
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β—― Betamethasone (Celestone) ☐ glucocorticoid that is administered IM in two injections, 24 hr apart, and requires a 24-hr period to be effective. The therapeutic action is to enhance fetal lung maturity and surfactant production.
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What are the nursing considerations for Nifedipine (Procardia, Adalat) relating to preterm labor?
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☐ Monitor for headache, flushing, dizziness, and nausea. These usually are related to orthostatic hypotension that occurs with administration. ☐ Should not be administered concurrent with magnesium sulfate. ☐ Instruct the client to slowly change positions from supine to upright and to sit until dizziness disappears. ☐ Inform the client to maintain adequate hydration to counter hypotension.
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What is a main nursing considerations for the administration of Magnesium sulfate relating to preterm labor?
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☐ Monitor the client closely. Tocolytic therapy should be discontinued immediately if the client exhibits manifestations of pulmonary edema, which includes chest pain, shortness of breath, respiratory distress, audible wheezing and crackles, and/or a productive cough containing blood-tinged sputum.
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What is a critical complication the nurse should monitor for when administering Magnesium sulfate?
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☐ Magnesium sulfate TOXICITY ☐ ANTIDOTE is Calcium gluconate Discontinue for any of the following adverse effects: Loss of deep tendon reflexes Urinary output less than 30 mL/hr Respiratory depression less than 12/min Pulmonary edema, and/or chest pain. ☐ Administer calcium gluconate as an antidote for magnesium sulfate toxicity.
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What are some other nursing considerations important to the administration of Magnesium sulfate?
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☐ Monitor for adverse effects. ☐ Contraindications for tocolysis include active vaginal bleeding, dilation of the cervix greater than 6 cm, chorioamnionitis, greater than 34 weeks of gestation, and acute fetal distress. ☐ Instruct the client to notify the nurse of blurred vision, headache, nausea, vomiting, or difficulty breathing.
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What are the nursing considerations for Indomethacin (Indocin) relating to preterm labor?
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☐ Monitor the client closely. ☐ Indomethacin treatment should not exceed 48 hr. ☐ Indomethacin should only be used if gestational age is less than 32 weeks of gestation. ☐ Monitor for postpartum hemorrhage related to reduced platelet aggregation. ☐ Administer indomethacin with food or rectally to decrease gastrointestinal distress. ☐ Notify the provider if the client reports blurred vision, headache, nausea, vomiting, or difficulty breathing. ☐ Monitor the neonate at birth.
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When should the nurse discontinue the administration of Indomethacin (Indocin)?
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Indomethacin (Indocin) should be discontinued IMMEDIATELY if the client exhibits manifestations of pulmonary edema: Chest pain SOB Respiratory distress Audible wheezing and crackles, and/or Productive cough containing blood-tinged sputum.
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What are the nursing considerations for Betamethasone (Celestone)?
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☐ Administer the medication deep into the gluteal muscle 24 and 48 hr prior to birth of a preterm neonate. ☐ Monitor the client and neonate for pulmonary edema by assessing lung sounds. ☐ Monitor for maternal and neonate hyperglycemia. ☐ Monitor the neonate for heart rate changes. ☐ Educate the client regarding signs of pulmonary edema (chest pain, shortness of breath, and crackles).
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Premature rupture of membranes (PROM)
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Spontaneous rupture of the amniotic membranes 1 hr or more prior to the onset of true labor. For most women, PROM signifies the onset of true labor if gestational duration is at term.
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Preterm premature rupture of membranes (PPROM)
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Preterm premature rupture of membranes (PPROM) is the premature spontaneous rupture of membranes after 20 weeks of gestation and prior to 37 weeks of gestation.
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What are the risk factors associated with PROM and PPROM?
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● Infection is the major risk of PROM and PPROM for both the client and the fetus. Once the amniotic membranes have ruptured, micro-organisms can ascend from the vagina into the amniotic sac. PPROM is often preceded by infection. ● Chorioamnionitis is an infection of the amniotic membranes. β—― There is an increased risk of infection if there is a lag period over the 24-hr period from when the membranes rupture to delivery.
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What assessment data could be observed in association with PROM and PPROM?
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β—― Client reports a gush or leakage of clear fluid from the vagina. β–  Temperature elevation β–  Increased maternal heart rate or FHR β–  Foul-smelling fluid or vaginal discharge β–  Abdominal tenderness β—― Assess for a prolapsed umbilical cord. β–  Abrupt FHR variable or prolonged deceleration β–  Visible or palpable cord at the introitus
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What are the lab tests confirming PROM?
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β—― A positive Nitrazine paper test (blue, pH 6.5 to 7.5) or β—― Positive ferning test is conducted on amniotic fluid to verify rupture of membranes.
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What are the nursing care considerations for a woman who has experienced PROM?
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β—― Prepare for birth if indicated. β—― Assess for evidence of infection, or indication of fetal/maternal compromise. β—― Obtain vaginal cultures for streptococcus ß-hemolytic, chlamydia, and Neisseria gonorrhoeae. β—― Avoid vaginal exams. β—― Provide reassurance to reduce anxiety. β—― Assess vital signs every 2 hr. Notify the provider of a temperature greater than 38ΒΊ C (100ΒΊ F). β—― Assess FHR and uterine contractions. β—― Advise the client to adhere to bed rest with bathroom privileges. β—― Encourage hydration. β—― Obtain a CBC. β—― Instruct the client to perform daily fetal kick counts and to notify the nurse of uterine contractions.
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If PROM has occurred, what medications would be administered?
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β—― Ampicillin (Omnipen) to treat infection β–  Obtain vaginal, urine, and blood cultures prior to administration of antibiotic. β—― Betamethasone (Celestone) to enhance fetal lung maturity and surfactant production. β–  Administered IM in 2 injections, 24 hr apart, and requires a 24-hr period to be effective.
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What are the nursing considerations regarding the administration of Betamethasone (Celestone)?
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β–  Administer the medication deep into the gluteal muscle 24 and 48 hr prior to birth of a preterm neonate. β–  Monitor the client and neonate for pulmonary edema by assessing lung sounds. β–  Monitor for maternal and neonate hyperglycemia. β–  Monitor the neonate for heart rate changes. β–  Educate the client regarding signs of pulmonary edema (chest pain, shortness of breath, and crackles).
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What are the discharge instructions for a woman who has PROM?
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β–  Expect that the client will be discharged home if dilation is less than 3 cm, no evidence of infection, no contractions, and no malpresentation. β–  Advise the client to adhere to limited activity with bathroom privileges. β–  Encourage hydration.
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What information would the nurse include in the client education for PROM and PPROM?
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β–  The client should conduct a self-assessment for uterine contractions. β–  The client should record daily kick counts for fetal movement. β–  The client should monitor for foul-smelling vaginal discharge. ☐ Refrain from inserting anything into the vagina. β–  The client should abstain from intercourse. β–  The client should avoid tub baths. β–  The client should wipe her perineal area from front to back after voiding and fecal elimination. β–  The client should take her temperature every 4 hr when awake and report a temperature that is greater than 38Β° C (100Β° F).
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A nurse is preparing to administer betamethasone acetate and betamethasone sodium phosphate (Celestone Soluspan) 6 mg IM to a client who will undergo a cesarean birth due to premature rupture of membranes. Available is betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg suspension per mL. How many mL should the nurse administer? (Round the answer to the nearest whole number.) mL
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ANS: 2 mL IM.
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A nurse in labor and delivery is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? A. Calcium gluconate B. Indomethacin (Indocin) C. Nifedipine (Procardia) D. Betamethasone (Celestone)
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ANS: D – Betamethasone A. INCORRECT: Calcium gluconate is administered as an antidote for magnesium sulfate toxicity. B. INCORRECT: Indomethacin is an NSAID used to suppress preterm labor by blocking prostaglandin production. C. INCORRECT: Nifedipine is a calcium channel blocker used to suppress uterine contractions. D. CORRECT: Betamethasone is a glucocorticoid that is given to clients in preterm labor to hasten surfactant production.
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A nurse is caring for a client who is receiving nifedipine (Procardia) for prevention of preterm labor. The nurse should monitor the client for which of the following clinical manifestations? A. Blood-tinged sputum B. Dizziness C. Pallor D. Somnolence
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ANS: B – Dizziness A. INCORRECT: Blood-tinged sputum production is an adverse affect associated with indomethacin (Indocin). B. CORRECT: Dizziness and lightheadedness are associated with orthostatic hypotension, which occurs when taking nifedipine. C. INCORRECT: Facial flushing and heat sensation are adverse effects associated with nifedipine. D. INCORRECT: Nervousness, jitteriness, and sleep disturbances are adverse effects associated with nifedipine.
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A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication. (Select all that apply.) A. Acute fetal distress B. Preterm labor C. Vaginal bleeding D. Cervical dilation greater than 6 cm E. Severe gestational hypertension
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ANS: A, C, D A. CORRECT: Acute fetal distress is a complication that is a contraindication for the use of magnesium sulfate therapy. B. INCORRECT: Preterm labor is an indication for the use of magnesium sulfate. C. CORRECT: Vaginal bleeding is a complication that is a contraindication for magnesium sulfate therapy. D. CORRECT: Cervical dilation greater than 6 cm is a complication that is a contraindication for magnesium sulfate therapy. E. INCORRECT: Severe gestational hypertension is an indication for the use of magnesium sulfate.
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A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following should be included in the teaching? A. Use a condom with sexual intercourse. B. Avoid bubble bath solution when taking a tub bath. C. Wipe from the back to front when performing perineal hygiene. D. Keep a daily record of fetal kick counts.
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ANS: D – The client should record daily fetal kick counts. A. INCORRECT: The client who has ruptured membranes should not insert anything into her vagina. B. INCORRECT: Showers should be taken, and tub baths should be avoided. C. INCORRECT: The client should be instructed that this is incorrect technique when performing perineal hygiene. D. CORRECT: The client should record daily fetal kick counts.
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A.) A nurse in a prenatal clinic is reviewing preterm labor with a newly hired nurse. How should the nurse describe the disorder?
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ANS: Uterine contractions and cervical changes that occur between 20 and 37 weeks of gestation.
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B.) A nurse in a prenatal clinic is reviewing preterm labor with a newly hired nurse. What three manifestations of subjective data for preterm labor would the nurse expect the newbie to understand?
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● Persistent low backache ● Pressure in the pelvis and cramping ● Gastrointestinal cramping, sometimes with diarrhea ● Urinary frequency ● Vaginal discharge
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C.) A nurse in a prenatal clinic is reviewing preterm labor with a newly hired nurse. What are at least three manifestations of objective data for preterm labor that the preceptor would verify understanding of with the new-hire?
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● Increase, change, or blood in vaginal discharge ● Change in cervical dilation ● Regular uterine contractions with a frequency of every 10 min or greater, lasting 1 hr or longer ● Premature rupture of membranes
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D. A nurse in a prenatal clinic is reviewing preterm labor with a newly hired nurse. What are at least two diagnostic procedures for preterm labor that the preceptor would ensure knowledge of with the new-hire?
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● Test for fetal fibronectin ● Ultrasound to measure endocervical length ● Cervical culture to detect presence of infectious organisms ● Biophysical profile ● Nonstress test ● Home uterine activity monitoring for uterine contractions