A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration?

The correct answer is A. Blood pressure 80/56 mm Hg.

A. A blood pressure of 80/56 mm Hg is the priority finding. Opioid analgesia can cause hypotension, and addressing low blood pressure is crucial to prevent maternal and fetal complications. The nurse should notify the healthcare provider promptly and implement interventions to improve blood pressure.

B. Profuse itching is a common side effect of opioids and is generally not considered a priority unless it becomes severe or is accompanied by other concerning symptoms.

C. A temperature of 38.2°C (100.8°F) may indicate a fever, but addressing hypotension takes precedence. Elevated temperature can be further assessed but is not the priority in this scenario.

D. The client reporting weakness of the lower extremities is a concerning symptom, but the priority is to address hypotension first, as it could be related to opioid-induced hypotension.

The correct answer is D. Fetal engagement

A. Fetal position, fetal lie, and fetal attitude are important aspects of the fetal presentation but are not specific considerations when performing an amniotomy.

B. Fetal lie is the relationship between the long axis of the fetus and the long axis of the mother. It is not directly relevant to the consideration of amniotomy.

C. Fetal attitude refers to the relationship of the fetal body parts to each other. It is not a specific consideration for amniotomy.

D. Fetal engagement is the correct consideration prior to amniotomy.

Fetal engagement refers to the descent of the fetal presenting part into the pelvis. Before performing an amniotomy, it is important to confirm that the fetal head is engaged in the pelvis, ensuring a lower risk of cord prolapse.