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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 D

Explanation

Choice A rationale

A rapid pulse is not typically associated with magnesium toxicity. Magnesium toxicity more commonly affects the nervous and muscular systems.

Choice B rationale

Tingling in toes can be a sign of early magnesium sulfate effects but not necessarily toxicity. It may indicate that the medication is starting to affect the nervous system.

Choice C rationale

Cool skin temperature is not a common sign of magnesium toxicity. Symptoms of magnesium toxicity are more related to neuromuscular and respiratory function.

Choice D rationale

Absent deep tendon reflexes are a key indicator of magnesium toxicity. This finding suggests that magnesium levels are high enough to depress neuromuscular function, requiring immediate medical intervention. .

Correct Answer is A

Explanation

Choice A rationale

Blood pressure should be addressed first due to the client’s elevated BP (144/92 mmHg), which is a potential sign of complications such as preeclampsia.

Choice B rationale

Pulse of 99 bpm is slightly elevated but not immediately concerning compared to the high BP.

Choice C rationale

Respirations are within normal range (17/min) and do not require immediate intervention.

Choice D rationale

Temperature of 100.4°F (38.0°C) is slightly elevated but not as critical as the high BP.

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