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?

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Tocolytic therapy is used to delay preterm labor and prevent premature birth. 2. Administering tocolytic therapy at 26 weeks of gestation allows time for corticosteroids to enhance fetal lung maturity. 3. Delaying labor at this stage can improve neonatal outcomes. 4. Other choices are incorrect because tocolytic therapy is not indicated for fetal death, Braxton-Hicks contractions, or post-term pregnancy.

Correct Answer: D

Rationale: The correct answer is D because urinary frequency is common in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus. This symptom typically improves by the end of the first trimester, as the uterus rises and reduces pressure on the bladder. Therefore, telling the client that it occurs during the first trimester and near the end of pregnancy is accurate. Choice A is incorrect because urinary frequency should not be ignored as it could be a sign of a urinary tract infection or other underlying issue. Choice B is incorrect because it inaccurately suggests that urinary frequency only lasts until the 12th week and implies that poor bladder tone is the sole factor influencing this symptom. Choice C is incorrect because while it is true that individual experiences can vary, there are general patterns and timelines for common pregnancy symptoms like urinary frequency.

Correct Answer: C

Rationale: Rationale: Option C, having the client pant during the next contractions, is the correct answer. At 7 cm dilation with a sudden urge to push, it indicates possible fetal descent. Panting can help prevent rapid descent and reducing the risk of cervical edema or injury. It allows time for the cervix to dilate fully before pushing, preventing premature pushing and potential complications. Option A is not a priority at this stage. Option B is incorrect as observing for crowning might lead to premature pushing. Option D is not necessary as voiding is not the priority right now.

Correct Answer: A

Rationale: The correct answer is A: Painless red vaginal bleeding. This finding supports the diagnosis of placenta previa due to the characteristic symptom of painless bleeding in the third trimester. Placenta previa occurs when the placenta partially or completely covers the cervix, leading to bleeding as the cervix begins to dilate. The other choices are incorrect because increasing abdominal pain with a non-relaxed uterus (B) may indicate placental abruption, abdominal pain with scant red vaginal bleeding (C) is not typical of placenta previa, and intermittent abdominal pain following the passage of bloody mucus (D) is more suggestive of preterm labor or bloody show.

Correct Answer: C

Rationale: The correct answer is C: Lecithin/sphingomyelin (L/S) ratio of 2:1. This ratio indicates fetal lung maturity as it signifies adequate production of surfactant in the fetal lungs, essential for proper lung function after birth. Absence of Phosphatidylglycerol (PG) (Choice A) indicates immaturity, Biophysical profile score of 8 (Choice B) assesses overall fetal well-being, not lung maturity, and Reactive nonstress test (Choice D) evaluates fetal well-being, not lung maturity. The L/S ratio of 2:1 is the most reliable indicator of fetal lung maturity.

Correct Answer: B

Rationale: The correct answer is B because removing extra blankets from the baby's crib reduces the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby on the stomach (Option A) increases the risk of SIDS. Padding the mattress (Option C) can also increase the risk of suffocation. Placing the crib next to a heater (Option D) can lead to overheating and poses a fire hazard. Removing extra blankets ensures a safe sleep environment for the baby.

Correct Answer: D

Rationale: The correct answer is D, Deep tendon reflexes of +1. In preeclampsia, deep tendon reflexes are typically hyperactive, not diminished (+1). This indicates hyporeflexia, which is inconsistent with preeclampsia. A is consistent with preeclampsia, as mild edema is common. B is also consistent, as proteinuria is a hallmark sign. C is consistent, as elevated blood pressure is a key feature. Therefore, D is the only choice that does not align with the expected findings in preeclampsia.

Correct Answer: D

Rationale: The correct answer is D: Assist the client to turn onto her side. This intervention is essential to improve blood flow to the placenta and fetus, thus helping to increase blood pressure and prevent hypotension. Turning the client onto her side can help relieve pressure on the vena cava, allowing for better circulation. A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading. B: Assisting the client to an upright position may worsen hypotension as it can further decrease blood flow to the placenta. C: Preparing for an immediate vaginal delivery is not necessary solely based on the client's blood pressure reading.

Correct Answer: D

Rationale: The correct answer is D: Encourage the client to empty her bladder every 2 hours. This is important to prevent bladder distention, which can impede fetal descent and progression of labor. A: Maintaining the client in the lithotomy position is unnecessary and may be uncomfortable. B: Performing frequent vaginal examinations increases the risk of infection and should be minimized. C: Reminding the client to bear down with each contraction is not appropriate during the active phase of the first stage of labor as it can lead to exhaustion and prolonged labor.