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 D
Explanation
Choice A rationale
Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.
Choice B rationale
Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.
Choice C rationale
Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.
Choice D rationale
A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .
Correct Answer is C
Explanation
Choice A rationale
The placenta does not provide thermoregulation; that function is managed by maternal thermoregulation and the amniotic fluid which insulates the fetus.
Choice B rationale
Amniotic fluid cushions the fetus from maternal movements, not the placenta. The placenta's role is more focused on nutrient and waste exchange.
Choice C rationale
The placenta facilitates metabolic functions and gas exchange, supplying oxygen and nutrients to the fetus while removing carbon dioxide and waste products, ensuring fetal development.
Choice D rationale
The placenta doesn't provide a sterile environment. This is accomplished by the amniotic sac and amniotic fluid. The placenta connects the fetus to maternal blood supply, ensuring necessary exchanges for fetal growth.