A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

A client who is experiencing preterm labor at 26 weeks of gestation

A client who is experiencing fetal death at 32 weeks of gestation

A client who has a post-term pregnancy at 42 weeks of gestation

A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation

Answer and Explanation

The Correct Answer is A

Choice A reason: A client who is experiencing preterm labor at 26 weeks of gestation is a suitable candidate for tocolytic therapy, because it can help delay the delivery and allow time for fetal lung maturation and transfer to a tertiary care center. Tocolytic therapy is indicated for clients who have regular uterine contractions and cervical changes before 37 weeks of gestation.

Choice B reason: A client who is experiencing fetal death at 32 weeks of gestation is not a suitable candidate for tocolytic therapy, because it has no benefit for the mother or the fetus. Tocolytic therapy is contraindicated for clients who have fetal demise, as it can increase the risk of infection and coagulation disorders.

Choice C reason: A client who has a post-term pregnancy at 42 weeks of gestation is not a suitable candidate for tocolytic therapy, because it can harm the mother and the fetus. Tocolytic therapy is contraindicated for clients who have post-term pregnancy, as it can increase the risk of placental insufficiency, fetal distress, and meconium aspiration.

Choice D reason: A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation is not a suitable candidate for tocolytic therapy, because it is not necessary or effective. Braxton-Hicks contractions are irregular and painless contractions that do not cause cervical changes or labor. They are normal and harmless, and do not require any intervention.

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Correct Answer is D

Explanation

Choice A reason: This statement is insensitive and dismissive, as it implies that the client's feelings are not valid or important. The nurse should not minimize the client's disappointment or guilt, but rather acknowledge and respect them.

Choice B reason: This statement is inaccurate and irrelevant, as it does not address the client's emotional needs or concerns. The nurse should not give false or misleading information, or focus on the physical aspects of recovery, but rather provide emotional support and education.

Choice C reason: This statement is presumptuous and unrealistic, as it assumes that the client wants or can have another pregnancy, and that a vaginal delivery is possible or preferable. The nurse should not make assumptions or promises, or compare different modes of delivery, but rather explore the client's feelings and expectations.

Choice D reason: This statement is empathetic and respectful, as it reflects the client's feelings and validates them. The nurse should use active listening and therapeutic communication skills, such as open-ended questions, clarifications, and summarizations, to help the client cope and express her emotions.

A. Use fingertips when calming the newborn. B. Position the premature infant on their abdomen. C. Keep the newborn in a well-lit nursery. D. Cluster the newborn's care activities.

Correct Answer is D

Explanation

Choice A reason: Using fingertips when calming the newborn is not recommended, as it can overstimulate the immature nervous system and cause stress. Instead, the nurse should use gentle, firm, and sustained touch, such as cupping the head and feet, or swaddling the newborn.

Choice B reason: Positioning the premature infant on their abdomen is contraindicated, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should position the newborn on their back or side, with a rolled blanket or towel to support the spine and prevent flattening of the head.

Choice C reason: Keeping the newborn in a well-lit nursery is not advisable, as it can interfere with the development of the circadian rhythm and sleep patterns. The nurse should provide a dark and quiet environment for the newborn, and expose them to natural light during the day.

Choice D reason: Clustering the newborn's care activities is beneficial, as it can reduce the number of disruptions and allow for longer periods of rest and growth. The nurse should plan and coordinate the care activities, such as feeding, bathing, changing, and assessing, to minimize the stress on the newborn.

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A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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