A nurse is preparing to assess a newborn who is post-term. Which of the following findings should the nurse expect? (Select all that apply)

The correct answer is a) A client who is experiencing preterm labor at 26 weeks of gestation.

Choice A reason:

Tocolytic therapy is primarily used to delay preterm labor, which is defined as labor occurring before 37 weeks of gestation. The goal of tocolytic therapy is to prolong pregnancy, allowing more time for fetal development, particularly lung maturation. At 26 weeks of gestation, the fetus is significantly premature, and delaying labor can improve neonatal outcomes by reducing the risks associated with preterm birth, such as respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. Tocolytics can help delay labor for 48 hours to 7 days, providing a critical window for administering corticosteroids to enhance fetal lung maturity.

Choice B reason:

Braxton-Hicks contractions, also known as “false labor,” are irregular and usually painless contractions that occur during pregnancy, typically starting in the second trimester. These contractions do not lead to cervical dilation and are not indicative of true labor. Therefore, administering tocolytic therapy to a client experiencing Braxton-Hicks contractions at 36 weeks of gestation is unnecessary and inappropriate. The primary purpose of tocolytics is to manage true preterm labor, not false labor.

Choice C reason:

A post-term pregnancy is defined as a pregnancy that extends beyond 42 weeks of gestation. In such cases, the primary concern is the potential for complications related to prolonged gestation, such as macrosomia, oligohydramnios, and placental insufficiency. Tocolytic therapy is not indicated for post-term pregnancies because the goal is not to delay labor but rather to manage the risks associated with prolonged pregnancy. Induction of labor or close monitoring is typically recommended for post-term pregnancies.

Choice D reason:

In the unfortunate event of fetal death at 32 weeks of gestation, the focus of care shifts to the safe and compassionate management of the mother’s health and well-being. Tocolytic therapy is not appropriate in this context, as there is no benefit to delaying labor. Instead, the healthcare team will discuss options for delivery and provide emotional support to the grieving parents. The priority is to ensure the mother’s physical and emotional health during this difficult time.

Choice A reason:

Assessing maternal blood glucose is important in various clinical scenarios, such as managing diabetes during pregnancy. However, it is not directly related to the immediate issue of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min is a critical sign that requires immediate intervention to prevent further complications.

Choice B reason:

Discontinuing the magnesium infusion is the priority intervention. Magnesium sulfate toxicity can lead to severe respiratory depression, hypotension, and loss of deep tendon reflexes. A respiratory rate of 10/min indicates significant respiratory depression, which can be life-threatening. Stopping the infusion immediately helps to prevent further accumulation of magnesium in the body and allows for the administration of the antidote, calcium gluconate, if necessary.

Choice C reason:

Preparing for an emergency cesarean birth is a critical intervention in cases of fetal distress or other obstetric emergencies. However, in this scenario, the immediate concern is the client’s respiratory depression due to magnesium sulfate toxicity. Addressing the respiratory issue takes precedence to stabilize the client before considering any surgical interventions.

Choice D reason:

Placing the client in Trendelenburg position is typically used to treat hypotension or shock by promoting venous return to the heart. While it can be beneficial in certain situations, it does not address the primary issue of respiratory depression caused by magnesium sulfate toxicity. The priority is to discontinue the magnesium infusion and manage the respiratory depression.