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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
Hyperbilirubinemia presents with jaundice (yellowing of the skin and eyes) and is caused by excess bilirubin in the blood. It doesn't typically involve a high-pitched cry, increased
muscle tone, or projectile vomiting.
Choice B rationale
Neonatal abstinence syndrome occurs in newborns exposed to addictive opiate drugs while in the mother’s womb. Symptoms include high-pitched crying, increased muscle tone,
yawning, poor feeding with vomiting, and tachypnea due to drug withdrawal.
Choice C rationale
Respiratory distress syndrome is primarily characterized by breathing difficulties, including rapid, shallow breathing and a grunting sound. Symptoms do not typically include high-
pitched cry or projectile vomiting.
Choice D rationale
Necrotizing enterocolitis involves severe inflammation and necrosis of the intestines. Symptoms include abdominal distension, vomiting bile, bloody stools, and apnea but not a high-
pitched cry or increased muscle tone.
Correct Answer is D
Explanation
Choice A rationale
Blue coloring of the hands and feet in an 8-hour-old newborn (acrocyanosis) is a common, benign finding as the newborn’s circulatory system adjusts post-birth. It does not require immediate intervention.
Choice B rationale
Small raised pearly spots on the nose (milia) are harmless and common in newborns. They do not necessitate any intervention.
Choice C rationale
An apical heart rate of 140 bpm is within the normal range for newborns and does not require intervention.
Choice D rationale
Nasal flaring and grunting are signs of respiratory distress in a newborn. This condition demands immediate intervention to ensure the newborn’s airway is clear and breathing is adequately supported.