A nurse is caring for a patient who has been admitted to the labor and delivery unit.
After reviewing the patient’s vital signs and nurse’s notes, what condition is the patient most likely experiencing, what actions should the nurse take to address that condition, and what parameters should the nurse monitor to assess the patient’s progress?
Potential Condition: Preterm labor
Actions to Take: Administer tocolytics
Parameters to Monitor: Frequency of contractions .
Parameters to Monitor: Frequency of contractions .
The Correct Answer is A
Potential Condition: Preterm labor. Based on the information provided, the patient is most likely experiencing preterm labor. Actions to Take: Administer tocolytics. If the patient is in preterm labor, the nurse should administer tocolytics to try to stop the contractions. Parameters to Monitor: Frequency of contractions. The nurse should monitor the frequency of contractions to assess the patient’s progress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While the fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum, it is not the priority in this case. The fundus, which is the top part of the uterus, typically descends at a rate of approximately one fingerbreadth (or one cm) per day, and by the 12th postpartum day, it should no longer be palpable.
Choice B rationale
A saturated perineal pad in 30 minutes is a sign of excessive bleeding, also known as postpartum hemorrhage. This is a serious condition that can lead to shock and other complications if not treated promptly. Therefore, this finding should be prioritized by the nurse.
Choice C rationale
Approximated edges of an episiotomy are a normal finding in the postpartum period. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening for delivery. After delivery, the episiotomy is sutured and should heal without complications with proper care. However, this is not the priority finding in this scenario.
Choice D rationale
Deep tendon reflexes 4+ could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. However, since the client is already 4 hours postpartum, this is less likely to be the priority.
Correct Answer is C
Explanation
Choice A rationale
Betamethasone does not increase the fetal heart rate. It is a corticosteroid given to pregnant women who are at risk of preterm delivery to enhance fetal lung maturity and prevent respiratory distress syndrome.
Choice B rationale
Betamethasone is not used to stop preterm labor contractions. Other medications, such as tocolytics, are used for this purpose.
Choice C rationale
This is the correct answer. Betamethasone is given to promote fetal lung maturity. It is usually given in two doses, 24 hours apart, and takes effect within 24 hours of administration.
Choice D rationale
Betamethasone does not halt cervical dilation. It is given to enhance fetal lung maturity, not to stop labor.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.