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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The fetal heartbeat can be heard with a Doppler at the fourth week of gestation is incorrect. At this early stage, the embryonic heart has only just begun to form, and its activity cannot be detected by Doppler.
Choice B rationale
The fetal heartbeat can be heard with a Doppler at the sixth week of gestation is incorrect. Although the heart begins to beat around this time, it is usually too faint to be detected by Doppler.
Choice C rationale
The fetal heartbeat can be heard with a Doppler at the seventh week of gestation is incorrect. It remains challenging to detect the fetal heartbeat this early with standard Doppler equipment.
Choice D rationale
The fetal heartbeat can be heard with a Doppler at the twelfth week of gestation is correct. By the end of the first trimester, the fetal heart is sufficiently developed and strong enough to be detected using Doppler ultrasound, allowing healthcare providers to monitor fetal well-being.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Choice A Rationale
Administer azithromycin 1 g PO one time: Anticipated. Azithromycin is commonly used to treat chlamydia infections during pregnancy and is considered safe.
Choice B Rationale
Administer ibuprofen 600 mg PO twice a day for pain: Contraindicated. Ibuprofen is generally avoided during pregnancy, especially in the third trimester, due to risks such as premature closure of the fetal ductus arteriosus.
Choice C Rationale
Notify all sexual partners within prior 30 days of the need for STI screening: Anticipated. Notification of sexual partners for STI screening is a standard public health practice to prevent the spread of infections.
Choice D Rationale
Administer ceftriaxone 250 mg IM now: Anticipated. Ceftriaxone is often used to treat gonorrhea infections during pregnancy and is considered safe for both mother and fetus.
Choice E Rationale
Repeat STI screening at next prenatal visit in 1 month: Anticipated. Repeating STI screening can help ensure that any new or untreated infections are identified and managed appropriately.
Choice F Rationale
Notify the appropriate public health agency: Anticipated. Reporting certain STIs to public health agencies is required by law to help track and control the spread of infections.
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