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:
To help stop your labor contractions.
To prevent an infection in your uterus.
To help mature your baby's lungs.
To decrease the pain from the contractions.
To decrease the pain from the contractions.
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 D
Explanation
Choice A rationale
Checking the blood sugar of a gestational diabetic is essential but not immediately life-threatening. Blood sugar levels should be monitored regularly throughout pregnancy for
diabetics to prevent complications. However, this does not represent an urgent priority when compared to the other options, which involve more immediate risks to life and health.
Choice B rationale
Assessing vaginal blood loss in a client recovering from a spontaneous abortion is crucial to monitor for hemorrhage or infection. Heavy bleeding could signal a serious complication
needing immediate intervention, though it is not the most immediate priority over monitoring fetal heart rate during active labor.
Choice C rationale
Monitoring the patellar reflexes of a client with pre-eclampsia without severe features can help in detecting early signs of progressing pre-eclampsia. While important, it is generally
not as critical as ensuring immediate fetal wellbeing, especially if reflexes do not present signs of worsening.
Choice D rationale
Checking the fetal heart rate in a client whose membranes have just ruptured is paramount. Rupture of membranes could lead to immediate complications such as umbilical cord
prolapse, leading to rapid fetal distress. Therefore, verifying fetal heart rate ensures that the fetus is not in immediate danger.
Correct Answer is C
Explanation
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.