A nurse is caring for a pregnant woman at 30 weeks of gestation in preterm labor. The woman's physician orders
betamethasone 12 mg IM for two doses, with the first dose to begin at 11 am. In implementing this order, the nurse should:
Consult the physician, because the dose is too high.
Schedule the second dose for 11 am on the next day.
Prepare to administer the medication intramuscularly between contractions.
The Correct Answer is C
Choice a) Consult the physician, because the dose is too high is incorrect because this is not a necessary or appropriate action for a nurse who is following a valid order for betamethasone. Betamethasone is a corticosteroid that can be used to accelerate fetal lung maturation and reduce the risk of respiratory distress syndrome and other complications in preterm infants. The recommended dose for betamethasone is 12 mg IM every 24 hours for two doses, which is exactly what the physician ordered. Therefore, there is no reason to question or consult the physician about the dose, as it is within the normal range and based on evidence-based practice.
Choice b) Schedule the second dose for 11 am on the next day is incorrect because this is not a correct or accurate way to implement the order for betamethasone. Betamethasone should be given at least 24 hours apart, but not more than 48 hours apart, to achieve optimal fetal lung development and neonatal outcomes. Scheduling the second dose for 11 am on the next day would result in a 24-hour interval between the doses, which is acceptable, but not ideal. The best time to schedule the second dose would be between 24 and 48 hours after the first dose, such as at 11 pm on the same day or at 7 am on the next day.
Choice c) Prepare to administer the medication intramuscularly between contractions is correct because this is the best and most appropriate way to implement the order for betamethasone. Betamethasone should be given by intramuscular injection in a large muscle mass, such as the deltoid or gluteus, using a 21-gauge needle and a syringe with an air lock. The injection site should be cleaned with alcohol and aspirated before injecting. The medication should be administered between contractions, when the uterine blood flow is maximal and the fetal absorption is optimal. The nurse should also monitor the woman and the fetus for any adverse effects of betamethasone, such as maternal hyperglycemia, hypertension, infection, or edema, or fetal tachycardia, hypoglycemia, or infection.
Choice d) Explain to the woman that this medication will reduce her heart rate and help her to breathe easier is incorrect because this is not a true or relevant statement about betamethasone. Betamethasone does not have any direct effect on the maternal heart rate or respiratory function, as it is mainly intended to improve the fetal lung maturation and reduce the risk of respiratory distress syndrome and other complications in preterm infants.
Betamethasone may cause some side effects such as increased blood pressure, blood sugar, or fluid retention in the mother, which may affect her cardiovascular or respiratory status indirectly. However, these effects are usually transient and mild, and do not outweigh the benefits of betamethasone for the fetus. Therefore, this statement is misleading and inaccurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: This is incorrect because preeclampsia is a condition characterized by hypertension, proteinuria, and edema that occurs after 20 weeks of gestation. It is not related to abruptio placentae, which is the premature separation of the placenta from the uterine wall. Preeclampsia does not cause petechiae or bleeding around the IV site, but it may cause headache, blurred vision, epigastric pain, or seizures.
Choice B: This is incorrect because anaphylactoid syndrome of pregnancy, also known as amniotic fluid embolism, is a rare and life-threatening complication that occurs when amniotic fluid enters the maternal circulation and triggers an allergic reaction. It is not related to abruptio placentae, but it may occur during labor, delivery, or shortly after birth. Anaphylactoid syndrome of pregnancy does not cause petechiae or bleeding around the IV site, but it may cause respiratory distress, hypotension, cardiac arrest, or disseminated intravascular coagulation.
Choice C: This is the correct answer because disseminated intravascular coagulation (DIC) is a condition in which the blood clotting system is activated abnormally, leading to excessive clot formation and consumption of clotting factors and platelets. This results in bleeding from various sites, such as the IV site, gums, nose, or vagina. DIC is a common complication of abruptio placentae, as the release of thromboplastin from the placenta triggers the clotting cascade. DIC can also cause organ failure, shock, or death if not treated promptly.
Choice D: This is incorrect because puerperal infection, also known as postpartum infection, is a bacterial infection that affects the uterus, vagina, bladder, or wound site after childbirth. It is not related to abruptio placentae, but it may occur due to prolonged labor, cesarean delivery, retained placenta, or poor hygiene. Puerperal infection does not cause petechiae or bleeding around the IV site, but it may cause fever, malaise, foul-smelling lochia, or pelvic pain.
Correct Answer is B
Explanation
Choice A) Monitor uterine contractions is incorrect because this is not the most urgent intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Uterine contractions can indicate labor or placental abruption, which are possible causes of bleeding in late pregnancy. However, they are not the only or the most reliable indicators of these conditions, as some women may have painless bleeding or contractions without bleeding. Moreover, monitoring uterine contractions does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion. Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Choice B) Assess fetal heart rate (FHR) and maternal vital signs is correct because this is the most important and essential intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Bleeding in late pregnancy can be caused by various conditions, such as placenta previa, placental abruption, uterine rupture, or vasa previa, which can compromise the blood supply and oxygen delivery to the mother and the fetus. Assessing FHR and maternal vital signs can help to determine the severity and cause of the bleeding, as well as guide further
interventions such as fluid resuscitation, oxygen therapy, blood transfusion, or emergency delivery. The normal FHR range for a fetus is 110 to 160 beats per minute, and it may vary with fetal activity or maternal position. The normal maternal vital signs are: blood pressure 120/80 mm Hg or lower, heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, and temperature 36.5°C to 37.5°C (97.7°F to 99.5°F). Any deviation from these ranges may indicate hypoxia, hypovolemia, shock, infection, or distress. Therefore, this intervention should be done as soon as possible for women who have bleeding in late pregnancy.
Choice c) Perform a venipuncture for hemoglobin and hematocrit levels is incorrect because this is not a priority intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Hemoglobin and hematocrit are blood tests that measure the amount of red blood cells and their percentage in the blood volume.
They can help to evaluate the extent of blood loss and the need for blood transfusion. However, they are not
immediate or accurate indicators of bleeding in late pregnancy, as they may take time to reflect the changes in blood volume or be affected by other factors such as hydration or hemodilution. Moreover, performing a venipuncture does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion.
Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
Choice d) Place clean disposable pads to collect any drainage is incorrect because this is not a priority intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Placing clean disposable pads can help to keep the perineal area clean and dry, as well as to estimate the amount and type of bleeding. However, it does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion. Moreover, it does not provide any information about the cause or severity of the bleeding, as it may be affected by factors such as gravity or pooling. Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.
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