A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take?

Administer betamethasone 12 mg IM.

Prepare the client for immediate delivery.

Administer hydralazine 25 mg IV.

Infuse a bolus of IV fluid.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Administering betamethasone 12 mg IM helps accelerate fetal lung maturity by stimulating the production of surfactant. This is crucial for a preterm baby, as immature lungs are one of the biggest risks in preterm labor. Administering betamethasone can significantly improve neonatal outcomes by reducing respiratory distress syndrome and other complications related to prematurity.

Choice B rationale

Preparing the client for immediate delivery is not the first action as the primary goal in managing preterm labor with an L/S ratio of 1: is to delay labor and enhance fetal lung maturity. Betamethasone administration is prioritized to maximize fetal lung development before considering delivery.

Choice C rationale

Administering hydralazine 25 mg IV is used to manage hypertension and is unrelated to enhancing fetal lung maturity in preterm labor. It is not indicated in this situation as the primary concern is not managing blood pressure.

Choice D rationale

Infusing a bolus of IV fluid might be used to manage preterm labor but does not directly address the need to improve fetal lung maturity. The main priority is administering steroids like betamethasone to expedite fetal lung development.

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Correct Answer is B

Explanation

Choice A rationale

Analysis of serum for tetanus antibodies is not an immediate action in acute injury scenarios. The priority is to provide immediate passive immunity.

Choice B rationale

Administration of tetanus immune globulin provides immediate passive immunity. This is crucial to prevent tetanus infection since the client has not been immunized since infancy.

Choice C rationale

Inducing labor to avoid tetanus in the fetus is not a recommended action. The focus should be on providing immediate protection to the mother to prevent infection.

Choice D rationale

Administration of tetanus immune globulin after delivery delays necessary immediate protection. The risk of tetanus infection is immediate, so prompt administration is required.

A. You will need to double your intake of iron during pregnancy. B. You will need to increase your calcium intake during breastfeeding. C. Vitamin E requirements decline during pregnancy due to the increase in body fat. D. Prenatal vitamins will meet your need for increased vitamin D during pregnancy.

Correct Answer is A

Explanation

Choice A rationale

Iron needs significantly increase during pregnancy to support the increased blood volume, the formation of the placenta, and the growth of the fetus. Pregnant women often require additional iron to prevent anemia and ensure adequate oxygen transport to the baby.

Choice B rationale

While calcium requirements do increase during breastfeeding to support milk production, this statement is not directly related to the nutritional needs during pregnancy. The focus during pregnancy should be on adequate intake of nutrients that support both maternal and fetal health.

Choice C rationale

Vitamin E requirements do not decline during pregnancy. In fact, the need for antioxidants like vitamin E may increase to protect both the mother and developing fetus from oxidative stress.

Choice D rationale

While prenatal vitamins are important for meeting various nutritional needs during pregnancy, they do not always provide sufficient vitamin D. Some women may need additional supplementation based on their dietary intake, sun exposure, and individual health needs.

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A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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