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A nurse in the labor and delivery unit is caring for a 31-year-old pregnant female client who is at 31 weeks of gestation.

History and Physical: The client is a Gravida 4 Para 3. She reports cramping and low back pain that started last night.

Vital Signs:

0900:

  • Temperature: 36.9°C (98.4°F)
  • Pulse rate: 87/min
  • Respiratory rate: 20/min
  • Blood Pressure: 129/70 mm Hg
  • Oxygen saturation: 98%

1000:

  • Pulse rate: 86/min
  • Respiratory rate: 18/min
  • Blood Pressure: 130/76 mm Hg
  • Oxygen saturation: 97%

Nurses Notes: At 0900, the client was placed on a fetal monitor, and the fetal heart tones (FHT) were recorded at 160/min. The client reported pain as a 6 on a 0 to 10 scale and requested pain medication. Vaginal examination showed 2 cm dilation, 80% effacement, and -1 station. At 1000, uterine contractions were observed every 2 to 4 minutes, lasting 60 to 80 seconds, with an FHT of 155/min. Provider was notified of the client's status and assessment, and new orders were received.

Medical History: The client has a history of three previous pregnancies (Gravida 4 Para 3).Querry: The nurse is contacting the primary health care provider regarding the client's status.

Which of the following interventions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

A.

Give betamethasone 12 mg IM now and repeat in 24 hr.

B.

Begin loading dose of magnesium sulfate 9 g over 30 min.

C.

Position the client in a lateral position.

D.

Administer terbutaline 0.25 mg subcutaneous stat.

E.

E. Prepare for an emergency cesarean birth

Question Solution

Correct Answer : A,B,C

Choice A: Give betamethasone 12 mg IM now and repeat in 24 hr.

Rationale: Betamethasone is administered to accelerate fetal lung maturity in cases of preterm labor. Given the client's gestational age of 31 weeks, this intervention is appropriate to help reduce the risk of respiratory distress syndrome in the newborn.

 

Choice B: Begin loading dose of magnesium sulfate 9 g over 30 min.

Rationale: Magnesium sulfate is used for neuroprotection of the fetus in preterm labor to reduce the risk of cerebral palsy. The loading dose is typically given to achieve therapeutic levels quickly.

 

Choice C: Position the client in a lateral position.

Rationale: Positioning the client in a lateral position helps improve uteroplacental blood flow and can reduce the intensity of contractions, which is beneficial in managing preterm labor.

 


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Correct Answer is B

Explanation

Choice A rationale

The fetal heartbeat cannot typically be heard via Doppler as early as 4 weeks of pregnancy. At this stage, the heart is still developing, and it is too soon for external detection with a Doppler device.

Choice B rationale

The fetal heartbeat is generally detectable by an external Doppler device around 10-12 weeks of pregnancy. This is the period when the heartbeat is strong enough to be picked up by the device.

Choice C rationale

Feeling the baby move, known as "quickening," typically occurs around 18-24 weeks of pregnancy, not 6 weeks. This sensation is different from hearing the heartbeat.

Choice D rationale

While the heart begins to form around week 5, it is not detectable by Doppler at 6 weeks. The technology does not have the sensitivity to detect such an early heartbeat externally.

Correct Answer is D

Explanation

Choice A rationale

Administering the rubella vaccine during pregnancy, including the third trimester, is contraindicated due to the risk of live vaccine transmission to the fetus. It is not recommended at any stage of pregnancy.

Choice B rationale

Advising the client to get the vaccine during her next pregnancy attempt is partly correct but lacks the immediacy needed to ensure she is immune before the next pregnancy. The vaccine should be given postpartum.

Choice C rationale

Administering the vaccine immediately during pregnancy is contraindicated due to potential risks to the fetus. Rubella vaccines contain live virus, which can cause fetal harm if given during pregnancy.

Choice D rationale

It is safest to administer the rubella vaccine postpartum, prior to hospital discharge, to ensure the client has immunity before any future pregnancies. This timing prevents any risk to the current fetus and ensures future fetal protection. .

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