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.
Give betamethasone 12 mg IM now and repeat in 24 hr.
Begin loading dose of magnesium sulfate 9 g over 30 min.
Position the client in a lateral position.
Administer terbutaline 0.25 mg subcutaneous stat.
E. Prepare for an emergency cesarean birth
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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View Related questions
Correct Answer is C
Explanation
Choice A rationale
Accelerations are increases in the fetal heart rate (FHR) above the baseline, typically in response to fetal movement or uterine contractions. They indicate a healthy, well-oxygenated
fetus and are not consistent with the described pattern of decelerations.
Choice B rationale
Late decelerations are characterized by a gradual decrease in FHR that begins after the contraction has started, with the lowest point of the deceleration (nadir) occurring after the
peak of the contraction. They are associated with uteroplacental insufficiency and fetal hypoxia, which is not described in the scenario.
Choice C rationale
Early decelerations are a gradual decrease in FHR that mirrors the contraction, starting with the contraction and returning to baseline as the contraction ends. The nadir of the
deceleration occurs at the peak of the contraction, which fits the pattern described.
Choice D rationale
Variable decelerations are abrupt decreases in FHR that can occur at any time during the contraction cycle, usually due to umbilical cord compression. They are not uniform in
relation to contractions and can vary in duration, depth, and timing, unlike the described pattern.
Correct Answer is ["B","E","F"]
Explanation
Choice A rationale:
The statement suggests supplementing with formula due to the baby’s weight loss. However, a 5% weight loss in the first few days is normal for breastfed infants, and formula
supplementation is not necessary unless recommended by a healthcare provider. Early breastfeeding should be encouraged to increase milk supply and support newborn weight gain.
Choice B rationale:
This statement correctly indicates that newborns should feed 8 to 12 times per day and on demand to ensure adequate nutrition and promote milk production. Frequent breastfeeding
helps establish and maintain milk supply.
Choice C rationale:
Using plastic-lined breast pads can retain moisture and increase the risk of infection or irritation. Sore nipples can be managed with lanolin creams, air-drying, and proper latching
techniques during breastfeeding.
Choice D rationale:
Drinking more whole milk is a common misconception and does not directly increase a mother's milk supply. Milk production is influenced by frequent breastfeeding, proper hydration,
and balanced nutrition, not by specific types of foods or drinks.
Choice E rationale:
Newborn stools transition from dark greenish meconium to yellow, seedy stools within the first few days of life as breastfeeding becomes established. This indicates effective feeding
and milk intake.
Choice F rationale:
It is normal for a breastfeeding mother’s breasts to feel full, warm, and slightly tender as her milk comes in. This indicates that the milk supply is increasing and the body is responding
to the newborn’s feeding needs.