A nurse is caring for several clients.The nurse should recognize that it is appropriate to administer tocolytic therapy to which of the following clients?
A client who has a post-term pregnancy at 42 weeks of gestation.
A client who is dilated to 7 cm and experiencing contractions every 3-4 minutes.
A client having Braxton-Hicks contractions at 36 weeks of gestation.
A client who is experiencing preterm labor at 32 weeks of gestation.
The Correct Answer is D
Choice A rationale
A post-term pregnancy at 42 weeks of gestation does not require tocolytic therapy. Tocolytics are used to stop preterm labor, not to manage full-term or post-term pregnancies.
Choice B rationale
A client who is dilated to 7 cm and experiencing contractions every 3-4 minutes is in active labor, and tocolytic therapy is not appropriate in this advanced stage of labor.
Choice C rationale
Braxton-Hicks contractions at 36 weeks of gestation are typically harmless and do not require tocolytic therapy. These contractions are usually irregular and do not lead to labor.
Choice D rationale
A client who is experiencing preterm labor at 32 weeks of gestation is an appropriate candidate for tocolytic therapy. The goal is to delay labor to allow for further fetal development and possibly administer corticosteroids to enhance fetal lung maturity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Complete the Sentence The priority intervention for the client with preterm premature rupture of membranes is to administer corticosteroids and administer prophylactic antibiotics.
Rationale for correct responses:
- Administer corticosteroids: This is necessary to promote fetal lung maturity, which is crucial given the gestational age of 34 weeks.
- Administer prophylactic antibiotics: This helps prevent maternal and fetal infection due to the rupture of membranes.
Rationale for incorrect responses:
- Initiate tocolytic therapy: This is not the priority as the client is not currently experiencing contractions.
- Prepare for immediate delivery: Immediate delivery is not indicated unless there are signs of fetal distress or maternal complications.
- Perform digital cervical examination: This increases the risk of infection and is contraindicated in cases of ruptured membranes.
- Administer Rh immunoglobulin: This is important but not the primary immediate intervention compared to corticosteroids and antibiotics.
- Discharge the client for outpatient follow-up: This is inappropriate due to the need for close monitoring and prevention of infection.
- Perform a biophysical profile: While useful, this is not a priority intervention compared to administering corticosteroids and antibiotics.
Correct Answer is D
Explanation
Choice A rationale
Observing the perineum for signs of crowning is important, but it doesn’t address the immediate need to manage the client’s urge to push. By the time crowning is visible, delivery is imminent, and the urge to push should have been managed earlier.
Choice B rationale
Helping the client to the bathroom to void might relieve some pressure but is not the immediate priority when the client feels the urge to push. Voiding can wait until contractions are managed.
Choice C rationale
Assisting the client into a supine position is not ideal for managing the urge to push. A supine position can increase discomfort and does not facilitate optimal delivery dynamics.
Choice D rationale
Assisting the client with quick shallow breathing helps manage the urge to push and prevents premature pushing, reducing the risk of cervical injury and aiding controlled delivery.
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