23. A client, who is gravida 3, para 1, is at 29 weeks' gestation. Upon examination, her cervix is 2 cm dilated, 40% effaced, and a –2 station. A physician admits the client for preterm labor. What is an appropriate nursing intervention for this client?
. Perform a nipple stimulation stress test to evaluate fetal well-being.
. Encourage adequate hydration.
. Administer misoprostol to decrease contractions.
. Encourage ambulation to prevent thrombophlebitis.
Test-Taking Tip
Since this client would most likely be on bedrest, with treatment aimed to decrease contractions, eliminate Answer 4 because ambulation may increase contractions and is not an appropriate intervention for preterm labor. Eliminate Answers 1 and 3 also because the actions are likely to stimulate contractions.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
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Answer 1 is incorrect because a nipple stimulation test will result in contractions, the opposite of expected management. A nonstress test and amniotic fluid index are appropriate for fetal surveillance. Answer 2 is correct because dehydration can lead to preterm labor contractions. Encouraging adequate hydration can decrease mild uterine irritability. Answer 3 is incorrect because misoprostol stimulates contractions; it is not a tocolytic. Answer 4 is incorrect because, although ambulation can prevent thrombophlebitis, sequential compression devices are more appropriate for this client.