A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
A client who is experiencing preterm labor at 26 weeks of gestation
A client who is experiencing fetal death at 32 weeks of gestation
A client who has a post-term pregnancy at 42 weeks of gestation
A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
The Correct Answer is A
Choice A reason: A client who is experiencing preterm labor at 26 weeks of gestation is a suitable candidate for tocolytic therapy, because it can help delay the delivery and allow time for fetal lung maturation and transfer to a tertiary care center. Tocolytic therapy is indicated for clients who have regular uterine contractions and cervical changes before 37 weeks of gestation.
Choice B reason: A client who is experiencing fetal death at 32 weeks of gestation is not a suitable candidate for tocolytic therapy, because it has no benefit for the mother or the fetus. Tocolytic therapy is contraindicated for clients who have fetal demise, as it can increase the risk of infection and coagulation disorders.
Choice C reason: A client who has a post-term pregnancy at 42 weeks of gestation is not a suitable candidate for tocolytic therapy, because it can harm the mother and the fetus. Tocolytic therapy is contraindicated for clients who have post-term pregnancy, as it can increase the risk of placental insufficiency, fetal distress, and meconium aspiration.
Choice D reason: A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation is not a suitable candidate for tocolytic therapy, because it is not necessary or effective. Braxton-Hicks contractions are irregular and painless contractions that do not cause cervical changes or labor. They are normal and harmless, and do not require any intervention.
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Correct Answer is A
Explanation
Choice A reason: This statement is correct, as these are the common complications of post-term infants, who are born after 42 weeks of gestation. Meconium aspiration can occur when the fetus passes meconium in utero and inhales it into the lungs, causing respiratory distress, inflammation, and infection. Hypoglycemia can occur due to the depletion of glycogen stores and the increased metabolic demands. Dry, cracked skin can occur due to the loss of vernix caseosa and the reduced amniotic fluid.
Choice B reason: This statement is incorrect, as these are the signs of neonatal hypocalcemia, which is a low level of calcium in the blood. Neonatal hypocalcemia can occur due to maternal diabetes, prematurity, or asphyxia, and can cause jitteriness, seizures, or tetany.
Choice C reason: This statement is incorrect, as these are the characteristics of preterm infants, who are born before 37 weeks of gestation. Excessive vernix caseosa covering the skin is a protective coating that prevents heat and water loss. Lethargy and RDS are signs of immaturity and underdevelopment of the central nervous system and the lungs.
Choice D reason: This statement is incorrect, as these are the features of infants with erythroblastosis fetalis, which is a hemolytic disease caused by the incompatibility of the Rh factor or the ABO blood group between the mother and the fetus. Golden yellow to green-stained skin and nails are due to the accumulation of bilirubin, which is a breakdown product of red blood cells. Absence of scalp hair and an increased amount of subcutaneous fat are due to the chronic hypoxia and edema.
Correct Answer is B
Explanation
Choice A reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause fetal distress, growth restriction, or demise. Continuous fetal monitoring can help detect and evaluate the fetal heart rate, variability, accelerations, decelerations, and contractions, and guide the management and intervention.
Choice B reason: This order requires clarification, as it is an inappropriate and contraindicated order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause seizures, stroke, or organ failure. Ambulation can increase the blood pressure, stimulate the labor, and worsen the condition. The client should be on bed rest, with the head of the bed elevated, and receive medications to lower the blood pressure and prevent seizures.
Choice C reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause edema, proteinuria, or oliguria. Obtaining a daily weight can help monitor the fluid status, the severity of the edema, and the response to the treatment.
Choice D reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause hyperreflexia, clonus, or seizures. Assessing deep tendon reflexes every hour can help evaluate the neuromuscular irritability, the risk of eclampsia, and the effect of magnesium sulfate.
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