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 B
Explanation
Choice A rationale
Maintaining a folic acid intake of 4 mcg per day is not sufficient. The recommended dose for pregnant women is 400-800 mcg to help prevent neural tube defects, but it is not specifically related to reducing the risk of preterm labor.
Choice B rationale
Increasing fluid intake to 8-10 (8 oz) glasses per day is recommended as it helps to maintain hydration, which is crucial in preventing preterm labor. Dehydration can cause uterine contractions, which can lead to preterm labor.
Choice C rationale
Consuming the recommended daily allowance of vitamin C (85 mg) is important for immune function and overall health but does not directly affect the risk of preterm labor.
Choice D rationale
Increasing caloric intake by 500 calories per day is typically recommended for breastfeeding mothers, not for preventing preterm labor during pregnancy. Proper nutrition is important, but overconsumption can lead to excessive weight gain.
Correct Answer is B
Explanation
Choice A rationale
A possible sign of pregnancy includes symptoms that are suggestive but not definitive, such as amenorrhea (absence of menstruation) or fatigue. These signs can have multiple causes and are not conclusive proof of pregnancy.
Choice B rationale
A positive sign of pregnancy includes objective evidence like fetal movement felt by the examiner, fetal heart sounds detected, or visualization of the fetus on ultrasound. These signs provide direct confirmation of pregnancy.
Choice C rationale
Presumptive signs of pregnancy are subjective experiences reported by the patient, such as nausea, breast tenderness, or quickening (feeling fetal movement). These signs are not confirmatory as they can occur in other conditions.
Choice D rationale
Probable signs of pregnancy include objective findings observed by a healthcare provider, such as uterine enlargement, but they are not definitive as they can also be caused by conditions like fibroids.
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