A nurse is caring for a 34-year-old female client who is at 34 weeks of gestation in the antepartum unit.
What is the most appropriate action the nurse should take next?
Administer Rh immunoglobulin (Rho(D) immune globulin)
Perform a continuous fetal heart rate monitoring
Prepare for emergent delivery
Administer a corticosteroid to enhance fetal lung maturity
The Correct Answer is D
A. Administer Rh immunoglobulin (Rho(D) immune globulin): This is important if the mother is Rh-negative, but there is no indication of Rh incompatibility in this scenario.
B. Perform continuous fetal heart rate monitoring: This is essential for ongoing assessment of fetal well-being but may not be the very first immediate action.
C. Prepare for emergent delivery: This would only be necessary if there were signs of fetal or maternal distress, which are not currently indicated.
D. Administer a corticosteroid to enhance fetal lung maturity: Administering corticosteroids like betamethasone or dexamethasone is crucial between 24 and 34 weeks of gestation to enhance lung maturity and reduce the risk of neonatal respiratory distress syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.76"]
Explanation
Step 1 is 3800 grams × 0.1 mg/kg. 3800 grams × 0.1 mg/kg = 380 mg.
Step 2 is 380 mg ÷ 0.5 mg/mL. 380 mg ÷ 0.5 mg/mL = 760 mL. Final calculated answer: 0.76 mL. .
Correct Answer is D
Explanation
Choice A rationale
Reassuring the client and rapidly completing the admission does not address the urgent symptom of an urge to have a bowel movement, which can indicate imminent delivery. Immediate assessment of labor progress is necessary.
Choice B rationale
Assisting the client to the bathroom to have a bowel movement may not be appropriate because the urge to defecate can signify the onset of the second stage of labor (pushing stage). Moving to the bathroom could risk an unattended delivery.
Choice C rationale
Assessing the fetal heart rate and uterine contractions with a routine tracing is important, but it does not directly address the urgent symptom of the urge to have a bowel movement. Vaginal exam takes priority to assess labor progress.
Choice D rationale
Assessing her progress of labor with a vaginal exam is the priority because the urge to have a bowel movement can signify that the baby is descending in the birth canal. This is the most immediate and necessary action to determine if delivery is imminent.
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