A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take?
Administer betamethasone 12 mg IM.
Prepare the client for immediate delivery.
Administer hydralazine 25 mg IV.
Infuse a bolus of IV fluid.
The Correct Answer is A
Choice A rationale
Administering betamethasone 12 mg IM helps accelerate fetal lung maturity by stimulating the production of surfactant. This is crucial for a preterm baby, as immature lungs are one of the biggest risks in preterm labor. Administering betamethasone can significantly improve neonatal outcomes by reducing respiratory distress syndrome and other complications related to prematurity.
Choice B rationale
Preparing the client for immediate delivery is not the first action as the primary goal in managing preterm labor with an L/S ratio of 1: is to delay labor and enhance fetal lung maturity. Betamethasone administration is prioritized to maximize fetal lung development before considering delivery.
Choice C rationale
Administering hydralazine 25 mg IV is used to manage hypertension and is unrelated to enhancing fetal lung maturity in preterm labor. It is not indicated in this situation as the primary concern is not managing blood pressure.
Choice D rationale
Infusing a bolus of IV fluid might be used to manage preterm labor but does not directly address the need to improve fetal lung maturity. The main priority is administering steroids like betamethasone to expedite fetal lung development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Rubella vaccination is contraindicated during pregnancy due to the risk of congenital rubella syndrome in the fetus. It should be administered postpartum if the client is non-immune.
Choice B rationale
Preterm labor is a concern at 28 weeks' gestation. Educating the client on signs and symptoms can help in early detection and management, potentially improving outcomes for both mother and baby.
Choice C rationale
Rh-negative mothers with a negative antibody screen should receive Rhogam at 28 weeks to prevent Rh sensitization. This is crucial to avoid hemolytic disease of the newborn in future pregnancies.
Choice D rationale
A positive urine analysis for leukocytes indicates a possible urinary tract infection. A clean catch urine culture is needed to identify the causative organism and guide appropriate antibiotic therapy.
Choice E rationale
The glucose challenge test result of 120 at 26 weeks is within normal limits, but a 3-hour diagnostic glucose tolerance test may be ordered if there's a high index of suspicion for gestational diabetes or other risk factors.
Choice F rationale
A blood transfusion is not indicated as the hemoglobin/hematocrit levels (11.0 mg/dl and 35%) are within acceptable limits for pregnancy.
Correct Answer is ["July 27"]
Explanation
Step 1 is to identify the first day of the last menstrual period (LMP), which is October 20.
Step 2 is to count back 3 months from October 20, resulting in July 20.
Step 3 is to add 1 year to July 20, resulting in July 20 of the following year.
Step 4 is to add 7 days to July 20, resulting in July 27.
Final calculated answer: July 27 of the following year.
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