A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?

The correct answer is a) A client who is experiencing preterm labor at 26 weeks of gestation.

Choice A reason:

Tocolytic therapy is primarily used to delay preterm labor, which is defined as labor occurring before 37 weeks of gestation. The goal of tocolytic therapy is to prolong pregnancy, allowing more time for fetal development, particularly lung maturation. At 26 weeks of gestation, the fetus is significantly premature, and delaying labor can improve neonatal outcomes by reducing the risks associated with preterm birth, such as respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. Tocolytics can help delay labor for 48 hours to 7 days, providing a critical window for administering corticosteroids to enhance fetal lung maturity.

Choice B reason:

Braxton-Hicks contractions, also known as “false labor,” are irregular and usually painless contractions that occur during pregnancy, typically starting in the second trimester. These contractions do not lead to cervical dilation and are not indicative of true labor. Therefore, administering tocolytic therapy to a client experiencing Braxton-Hicks contractions at 36 weeks of gestation is unnecessary and inappropriate. The primary purpose of tocolytics is to manage true preterm labor, not false labor.

Choice C reason:

A post-term pregnancy is defined as a pregnancy that extends beyond 42 weeks of gestation. In such cases, the primary concern is the potential for complications related to prolonged gestation, such as macrosomia, oligohydramnios, and placental insufficiency. Tocolytic therapy is not indicated for post-term pregnancies because the goal is not to delay labor but rather to manage the risks associated with prolonged pregnancy. Induction of labor or close monitoring is typically recommended for post-term pregnancies.

Choice D reason:

In the unfortunate event of fetal death at 32 weeks of gestation, the focus of care shifts to the safe and compassionate management of the mother’s health and well-being. Tocolytic therapy is not appropriate in this context, as there is no benefit to delaying labor. Instead, the healthcare team will discuss options for delivery and provide emotional support to the grieving parents. The priority is to ensure the mother’s physical and emotional health during this difficult time.

Choice A Reason:

Witnessing the signature for informed consent for surgery is important but not the immediate priority. The client’s vital signs indicate potential hemodynamic instability (low blood pressure and high heart rate), which requires prompt intervention to stabilize the client before any surgical procedures can be considered.

Choice B Reason:

Initiating IV access is the priority action. This allows for the administration of fluids and medications, which is crucial in managing the client’s hemodynamic status. The client’s low blood pressure and high heart rate suggest hypovolemia, likely due to significant blood loss. Immediate IV access enables rapid fluid resuscitation and preparation for potential blood transfusions, which are essential to stabilize the client1.

Choice C Reason:

Inserting an indwelling urinary catheter is necessary for monitoring urine output, which is an important indicator of renal perfusion and overall fluid status. However, it is not the immediate priority compared to establishing IV access, which directly addresses the client’s hemodynamic instability.

Choice D Reason:

Preparing the abdominal and perineal areas is a preparatory step for potential surgical intervention. While important, it is not the immediate priority. Stabilizing the client’s condition through IV access and fluid resuscitation takes precedence to ensure the client is in a stable condition for any subsequent procedures.