A nurse is admitting a client who is in pre-term labor at 34 weeks of gestation and has ruptured membranes and oligohydramnios.
Which of the following actions should the nurse take first?
Administer IV fluids
Obtain a urine specimen
Assess fetal heart rate
Insert an indwelling urinary catheter
The Correct Answer is C
This is because assessing fetal heart rate is the most important action to take first when a client has prelabor rupture of membranes (PROM) at 34 weeks of gestation and oligohydramnios. Fetal heart rate can indicate fetal well-being, distress, or infection. Oligohydramnios can increase the risk of umbilical cord compression and fetal hypoxia.
Choice A is wrong because administering IV fluids is not the first priority in this situation. IV fluids may be given to prevent dehydration, enhance uterine blood flow, or augment labor, but they are not as urgent as assessing fetal heart rate.
Choice B is wrong because obtaining a urine specimen is not the first priority in this situation. A urine specimen may be obtained to check for infection, proteinuria, or glucose levels, but they are not as urgent as assessing fetal heart rate.
Choice D is wrong because inserting an indwelling urinary catheter is not the first priority in this situation. An indwelling urinary catheter may be inserted to monitor fluid balance, prevent bladder distension, or reduce the risk of infection, but they are not as urgent as assessing fetal heart rate.
Normal ranges for fetal heart rate are 110 to 160 beats per minute. Oligohydramnios is defined as an amniotic fluid index of less than 5 cm.
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Correct Answer is B
Explanation
Prepare for an emergency cesarean section.This is because the client has pre-term labor that has not responded to tocolytic therapy, which are drugs that are used to delay delivery for a short time.The client’s cervix is dilated to 4 cm and she is experiencing regular contractions every 3 minutes, which are signs of active labor.The baby is at 33 weeks of gestation, which is premature and may have complications such as respiratory distress syndrome or bleeding in the brain.
Therefore, the client needs an emergency cesarean section to deliver the baby as soon as possible and prevent further risks.
Choice A is wrong because administering magnesium sulfate intravenously is a type of tocolytic therapy that the client has already failed.Magnesium sulfate may also have side effects such as nausea, vomiting, flushing, headache, and muscle weakness.
Choice C is wrong because placing the client in Trendelenburg position, which is lying on the back with the feet elevated above the head, is not recommended for preterm labor.This position may increase the risk of aspiration, decrease cardiac output, and impair gas exchange.
Choice D is wrong because administering antibiotics prophylactically is not indicated for preterm labor unless there is evidence of infection in the uterus or membranes.
Antibiotics may also cause allergic reactions or bacterial resistance
Correct Answer is C
Explanation
This medication will help relax my uterus and stop contractions.
Magnesium sulfate is a tocolytic, a medication used to suppress uterine contractions and delay preterm delivery.The exact mechanism through which magnesium sulfate inhibits contractions is unknown, but researchers believe it likely works by lowering calcium levels in the uterine muscles.
Choice A is wrong because magnesium sulfate is not used to prevent seizures in case of preeclampsia.
Preeclampsia is a condition characterized by high blood pressure and protein in the urine during pregnancy.Magnesium sulfate may be used to treat seizures if they occur with eclampsia, which is a severe complication of preeclampsia.
Choice B is wrong because magnesium sulfate does not help mature the baby’s lungs in case of preterm birth.
Magnesium sulfate may have some neuroprotective effects for the baby, but it does not affect lung development.Steroids are usually given to pregnant women at risk of preterm delivery to help accelerate fetal lung maturation.
Choice D is wrong because magnesium sulfate does not lower blood pressure in case it gets too high.
Magnesium sulfate may have some vasodilatory effects, but it is not used as an antihypertensive agent.Other medications, such as hydralazine or labetalol, are used to treat high blood pressure during pregnancy.
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