A nurse is developing a plan of care for a client who is in the latent phase of labor.
Which of the following interventions should the nurse include in the plan to manage the client's pain?

Choice A rationale

A positive pregnancy test detects the presence of human chorionic gonadotropin (hCG) in urine or blood. While highly suggestive, it is classified as a probable sign because certain conditions other than pregnancy can elevate hCG levels, although these are rare, making it not definitively diagnostic.

Choice B rationale

Amenorrhea, the cessation of menstruation, is a common early indicator of pregnancy due to hormonal changes, specifically rising progesterone levels that inhibit follicular development and uterine shedding. However, various factors unrelated to pregnancy, such as stress or hormonal imbalances, can also cause amenorrhea, categorizing it as a presumptive sign.

Choice C rationale

Fetal heart sounds, when auscultated, are a definitive sign of pregnancy because they directly confirm the presence of a viable fetus. This auditory confirmation is unambiguous and cannot be attributed to any other condition, making it a positive sign of pregnancy.

Choice D rationale

Chadwick sign refers to the bluish-purple discoloration of the cervix, vagina, and labia due to increased vascularity and blood flow, typically observed around 6-8 weeks of gestation. While highly indicative of pregnancy, it is considered a probable sign because other conditions can also cause pelvic congestion, although less commonly.

The nurse should anticipate the provider will prescribe terbutaline and betamethasone.

Rationale for correct answers:
Terbutaline is a beta-2 adrenergic agonist that relaxes uterine smooth muscle by increasing intracellular cyclic AMP, reducing calcium influx, and thus inhibiting contractions. It is commonly used as a tocolytic to delay preterm labor, allowing time for fetal maturation. Betamethasone is a corticosteroid given to accelerate fetal lung maturity by stimulating surfactant production in the fetal lungs, which significantly reduces the risk of respiratory distress syndrome in neonates born between 24 and 34 weeks gestation. The normal fetal fibronectin level is ≤0.05 mcg/mL; a value above this, as in this client (0.09 mcg/mL), indicates increased risk of preterm birth, supporting the use of these medications.

Rationale for incorrect answers:
Oxytocin (Response 1) stimulates uterine contractions via oxytocin receptors, promoting labor induction or augmentation. Administering oxytocin before term or in preterm labor is contraindicated because it can worsen contractions, precipitating early delivery.

Betamethasone (Response 1) is not used to stop contractions but to promote fetal lung maturity. It does not act as a tocolytic; thus, it is not prescribed alone to delay labor.

Misoprostol (Response 1) is a prostaglandin E1 analog that promotes cervical ripening and uterine contractions, making it inappropriate in preterm labor management, where delaying labor is the goal.

Oxytocin (Response 2) serves no purpose in fetal lung maturation and instead promotes contractions; thus, it is contraindicated here.

Ondansetron (Response 2) is an antiemetic without effects on uterine activity or fetal lung maturity; its use is unrelated to preterm labor management.

Misoprostol (Response 2) induces labor and cervical changes and is contraindicated in preterm labor where prolonging pregnancy is desired.

Take-home points:

• Terbutaline delays preterm labor by relaxing uterine muscles, buying critical time for fetal development.
• Betamethasone accelerates fetal lung maturity by stimulating surfactant production, reducing neonatal respiratory complications.
• Oxytocin and misoprostol induce labor and are contraindicated in preterm labor management aiming to delay delivery.
• Fetal fibronectin levels above 0.05 mcg/mL indicate increased risk of preterm birth, guiding tocolytic and steroid therapy.