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A preterm labor client at 30 weeks' gestation reported rupture of membranes 4 hours ago. This was confirmed on examination. The nurse prepares to administer IM dexamethasone. When the client asks why she is receiving the drug, the nurse replies:

A.

To help stop your labor contractions.

B.

To prevent an infection in your uterus.

C.

To help mature your baby's lungs.

D.

To decrease the pain from the contractions.

E.

To decrease the pain from the contractions.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Dexamethasone does not directly stop labor contractions; instead, it is used to enhance fetal lung maturity.

 

Choice B rationale

Dexamethasone is not for infection prevention; antibiotics are used for that purpose in cases of premature rupture of membranes.

 

Choice C rationale

Dexamethasone is administered to enhance fetal lung maturity, reducing the risk of respiratory distress syndrome in preterm infants.

 

Choice D rationale

Dexamethasone is not used for pain relief in preterm labor; other medications are prescribed for pain management.


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Correct Answer is B

Explanation

Choice A rationale

Prior amniotic fluid leakage is not a required criterion for amniotomy. The main concern is cervical readiness and fetal head position, not previous leakage.

Choice B rationale

The fetal head engaged in the maternal pelvis ensures proper pressure and position for safe amniotomy. Engagement reduces the risk of umbilical cord prolapse and injury.

Choice C rationale

Certification of the nurse for amniotomy is not a standard criterion. The procedure is performed by qualified professionals, but certification isn't a prerequisite for the procedure to be scheduled.

Choice D rationale

Ultrasound to check the umbilical cord's position isn't a standard pre-amniotomy criterion. While it can be useful, the primary concern is the fetal head engagement and cervical readiness.

Correct Answer is D

Explanation

Choice A rationale

Reflexes of 3+ indicate hyperreflexia, common in pre-eclampsia, but not necessarily critical. Monitoring is essential but not an emergency.

Choice B rationale

Urinary output of 30 mL/hr is within the acceptable range but requires monitoring for any changes. It's not a critical alert.

Choice C rationale

A respiratory rate of 16 rpm is normal and does not indicate immediate risk requiring physician notification.

Choice D rationale

Serum magnesium level of 10 mg/dL is significantly high, indicating potential toxicity. Immediate physician notification is critical to adjust magnesium sulfate administration.

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