A nurse is providing education to a client and her partner about pre-term labor.

Which intervention should the nurse include in the teaching plan to address possible outcomes and complications?

Administering intravenous fluids

Administering tocolytics

Administering corticosteroids

Providing emotional support

Answer and Explanation

The Correct Answer is C

Corticosteroids are given to pregnant women who are at risk of preterm labor to help mature the lungs of the fetus and reduce the risk of respiratory distress syndrome and other complications. Corticosteroids also have a protective effect on the brain and reduce the risk of bleeding and cerebral palsy.

Choice A is wrong because administering intravenous fluids is not a specific intervention to address possible outcomes and complications of preterm labor. Intravenous fluids may be given to correct dehydration or electrolyte imbalance, but they do not prevent or treat preterm labor.

Choice B is wrong because administering tocolytics is an intervention to delay preterm labor, not to address possible outcomes and complications.

Tocolytics are drugs that inhibit uterine contractions and prolong pregnancy for a short period of time, usually 24 to 48 hours, to allow for the administration of corticosteroids or the transfer of the mother to a facility with neonatal intensive care.

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Correct Answer is A

Explanation

Assess the client’s vital signs.

The nurse should first assess the client’s vital signs to determine the severity of the situation and identify any signs of infection, bleeding, or shock.

The nurse should also monitor the fetal heart rate to assess fetal well-being.

Choice B is wrong because a sterile vaginal exam is not indicated for a client who reports lower abdominal cramping and may increase the risk of infection or rupture of membranes.

Choice C is wrong because administering tocolytic medication is not the first action the nurse should take.

Tocolytic medication may be used to inhibit uterine contractions and prolong pregnancy, but only after assessing the client’s and fetus’s condition and obtaining a prescription from the provider.

Choice D is wrong because monitoring the fetal heart rate is not the first action the nurse should take.

Monitoring the fetal heart rate is important to assess fetal well-being, but it does not take priority over assessing the client’s vital signs.

A. Assess fetal heart rate and activity B. Perform a nitrazine test on the fluid C. Administer oxytocin (Pitocin) IV infusion D. Place the client in Trendelenburg position

Correct Answer is A

Explanation

Assess fetal heart rate and activity.

The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk forpremature rupture of membranes (PROM), which can lead toinfection,cord prolapse, andfetal distress.Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.

Choice B is wrong because performing a nitrazine test on the fluid is not the first action.A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.

Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation.Oxytocin is used to induce or augment labor, but it can causeuterine hyperstimulation,fetal distress, andplacental abruptionif given to a client who has PROM.

Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM.Trendelenburg position can increase the risk ofcord prolapseandaspirationin this situation.

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A nurse is providing education to a client and her partner about pre-term labor. Which intervention should the nurse include in the teaching plan to address possible outcomes and complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 32 weeks of gestation and reports lower abdominal cramping. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 33 weeks of gestation and has pre-term labor. The client reports a sudden gush of fluid from her vagina. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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A nurse is providing education to a client and her partner about pre-term labor.

Which intervention should the nurse include in the teaching plan to address possible outcomes and complications?