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Which of the following is the appropriate nursing care outcome for a client who suddenly develops anaphylactoid syndrome of pregnancy (ASP) during labor?

A.

Client will be infection free at discharge.

B.

Client will exhibit normal breathing function at discharge.

C.

Client will exhibit normal gastrointestinal function at discharge.

D.

Client will void without pain at discharge.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While infection prevention is vital, ensuring breathing function is more critical after ASP.

 

Choice B rationale

ASP affects the respiratory system severely; thus, restoring normal breathing is a primary goal.

 

Choice C rationale

Gastrointestinal function is less immediately affected by ASP compared to respiratory issues.

 

Choice D rationale

Voiding without pain is important, but respiratory stability takes precedence.


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Correct Answer is C

Explanation

Choice A rationale

Magnesium sulfate is primarily used for neuroprotection in preterm infants and to prevent seizures in severe preeclampsia, not as a first-line tocolytic for preterm labor.

Choice B rationale

Morphine sulfate is an opioid analgesic used for pain management, not for inhibiting preterm labor contractions.

Choice C rationale

Terbutaline is a beta-agonist used as a tocolytic to relax uterine muscles and delay preterm labor. It helps decrease the intensity and frequency of contractions, making it suitable for managing preterm labor.

Choice D rationale

Betamethasone is a corticosteroid used to accelerate fetal lung maturity in preterm labor, not for direct contraction inhibition.

Correct Answer is B

Explanation

Choice A rationale

Swaddling provides warmth but doesn't address jitteriness, which may be due to hypoglycemia.

Choice B rationale

Jitteriness in a newborn can indicate hypoglycemia. Prompt glucose assessment is crucial for early detection and management.

Choice C rationale

Feeding could help with glucose levels, but without knowing the glucose status, it might not be the immediate priority.

Choice D rationale

Routine medications are important but not as urgent as addressing possible hypoglycemia in a jittery baby.

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