Health Promotion and Maintenance
1. A client who is 23 years old, gravida 2, para 1 with a twin gestation, is admitted to labor and delivery at 29 weeks' gestation with complaints of lower abdominal pain and decreased fetal movement. Which interventions should a nurse perform? Select all that apply.
. Place the client on electronic fetal monitor.
. Administer betamethasone IM.
. Perform nipple stimulation stress test.
. Limit oral fluid intake.
. Place client on strict bedrest.
Test-Taking Tip
Eliminate Answers 3 and 4 because these actions are contraindicated in preterm labor. Since pregnancy increases the chance for developing blood clots, strict bedrest also increases the chance of developing blood clots; therefore, eliminate Answer 5 also.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Health Promotion and Maintenance
. .
Answer 1 is correct because placing the client on an electronic fetal monitor is an appropriate intervention to evaluate uterine contractions and determine fetal well-being. Evaluate of fetal well-being is very important for this client because of her complaint of decreased fetal movement. Answer 2 is correct because betamethasone is a corticosteroid used to help stimulate fetal lung maturity in infants who are preterm. Answer 3 is incorrect because performing a nipple stimulation test is inappropriate for a client who is in preterm labor; stimulating nipples may stimulate uterine contractions, which is contraindicated in preterm labor. Answer 4 is incorrect because adequate hydration (not limiting oral fluids) is important to decrease uterine contraction in clients who are in preterm labor. Answer 5 is incorrect because placing the client on strict bedrest increases the chance of developing deep vein thrombosis. Modified bedrest is the appropriate management for this client.