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A nurse is caring for a 28-year-old female client who is gravida 1 para 0 at 32 weeks of gestation in the prenatal unit.
Exhibit 1: History and PhysicalThe client is a 28-year-old female, gravida 1 para 0 at 32 weeks of gestation. She reports cramping and low back pain that started about 3 hours ago, with pain rated 2 on a scale of 0 to 10. She believes the contractions feel stronger than Braxton Hicks and expresses concern that it's too early for labor pains. The client mentions a small amount of urinary leakage earlier in the day, but no vaginal bleeding. She decided to come in for evaluation upon her doctor's advice.Exhibit 2: Nurses' NotesAt 0900, the client stated that she began experiencing cramping and low back pain approximately 3 hours ago, rating the pain as 2 out of 10. She described the contractions as stronger than Braxton Hicks but believed they were not labor pains. She also mentioned experiencing a small amount of urinary leakage earlier in the day, with no vaginal bleeding reported. The external fetal monitor indicated contractions every 5 minutes, lasting 30 seconds each, with moderate intensity upon palpation. Fetal heart rate was recorded at 140 beats per minute. A vaginal exam revealed a closed cervix that was 80% effaced, with clear mucus discharge observed on the exam glove.Exhibit 3: Vital SignsBlood Pressure: 120/80 mmHgHeart Rate: 80 bpmRespiratory Rate: 18 breaths/minTemperature: 98.6°F (37°C)Oxygen Saturation: 98%Exhibit 4: Physical Examination ResultsUpon physical examination, the client appeared anxious but was otherwise in stable condition. Her abdomen was soft and non-tender, with no signs of rigidity. Fetal movements were noted to be active. The client had no edema in her extremities, and her reflexes were normal. Auscultation of the lungs revealed clear breath sounds bilaterally. Cardiovascular examination showed a regular heart rhythm without any murmurs. The nurse is providing teaching about tocolytic medication. Which of the following statements should the nurse include? Select all that apply.

A.

"I will inject this medication under your skin."

B.

"You may experience a headache after receiving this medication."

C.

"It is common for this medication to make you feel jittery."

D.

"This medication should decrease your contractions."

Question Solution

Correct Answer : B,C,D,E,F

A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.

 

B. "You may experience a headache after receiving this medication."
Some tocolytic medications can cause headaches as a side effect.


C. "It is common for this medication to make you feel jittery."
Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.

D. "This medication should decrease your contractions."
The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.


E. "I'll check your reflexes frequently while you are receiving this medication."
Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.


F. "This medication can make your heart beat faster."
Tocolytic medications, such as terbutaline, can increase heart rate.


G. "This medication can increase your blood pressure.":

Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.
 


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Correct Answer is A

Explanation

Choice A rationale

Checking the client's temperature frequently following the procedure is crucial. An amniotomy increases the risk of infection, so frequent monitoring of temperature helps in early

detection and management of any potential infections.

Choice B rationale

Inserting misoprostol rectally every 2 hours following the procedure is not recommended. Misoprostol is a medication used for inducing labor or controlling postpartum hemorrhage,

not for routine use post-amniotomy.

Choice C rationale

Obtaining a biophysical profile during the procedure is not relevant. A biophysical profile is an assessment of fetal well-being and is not typically performed during amniotomy.

Choice D rationale

Performing effleurage to the client's abdomen during the procedure is not necessary. Effleurage is a massage technique used for pain relief during labor, but it is not related to the management of an amniotomy. .

Correct Answer is B

Explanation

Choice A rationale

Cesarean birth is not necessarily required for GBS-positive clients as long as IV antibiotic prophylaxis is administered during labor to prevent transmission to the newborn.

Choice B rationale

IV antibiotic prophylaxis, typically with penicillin or ampicillin, is given to GBS-positive clients during labor to prevent neonatal GBS infection.

Choice C rationale

Obtaining a vaginal culture at 39 weeks of gestation is not necessary if the client was already screened and found positive for GBS at 36 weeks.

Choice D rationale

Metronidazole is used to treat bacterial vaginosis or trichomoniasis, not GBS infection; thus, it is not appropriate for this scenario. .

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