The nurse is caring for a client at 34 weeks' gestation with suspected preterm labor. What is the priority nursing action?

Correct Answer: A

Rationale: The correct answer is A: Administer corticosteroids as prescribed. Administering corticosteroids helps accelerate fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. It is the priority action in suspected preterm labor at 34 weeks' gestation. Explanation for why other choices are incorrect: B: Encouraging ambulation may not be safe in preterm labor as it can increase the risk of delivering the baby prematurely. C: Providing a high-protein snack is not the priority action in suspected preterm labor. D: Monitoring maternal blood pressure is important, but not the priority in this situation where the focus is on preventing complications for the preterm infant.

Correct Answer: C

Rationale: The correct answer is C: Deep tendon reflexes +4. In severe preeclampsia, increased reflexes indicate possible progression to eclampsia with seizures. Immediate intervention is needed to prevent seizures. Choice A is not urgent unless higher proteinuria levels are present. Choice B is within normal range. Choice D is concerning but not as urgent as managing potential seizures.

Correct Answer: A

Rationale: The correct answer is A: Magnesium sulfate. This medication is commonly prescribed for preterm labor to relax the uterine muscles and prevent contractions. It helps delay labor and reduce the risk of preterm birth. Methyldopa (B) is used for managing hypertension, not preterm labor. Rho(D) immune globulin (C) is given to Rh-negative mothers to prevent hemolytic disease in newborns. Oxytocin (D) is used to induce or augment labor, not for suspected preterm labor. Therefore, A is the most appropriate choice for managing preterm labor.

Correct Answer: B

Rationale: The correct answer is B: Variable decelerations on the fetal monitor. This finding suggests umbilical cord prolapse because the cord can become compressed during contractions, leading to variable decelerations. It is a serious complication that requires immediate intervention to prevent fetal distress. A: Clear amniotic fluid is a normal finding after rupture of membranes. C: Contractions every 2 minutes may indicate tachysystole, but not specifically cord prolapse. D: Maternal blood pressure is not directly related to cord prolapse.

Correct Answer: A

Rationale: The correct answer is A because the client's comparison of receiving a Depo-Provera injection to a rubella injection is incorrect. Depo-Provera is a hormonal contraceptive injection that does not have the same administration process or purpose as a rubella vaccination. This indicates a lack of understanding about the medication. Choice B is not the correct answer because it shows the client's awareness of the importance of weight management and exercise in conjunction with receiving the injection. Choice C is not the correct answer because it demonstrates the client's understanding of the need for a follow-up appointment in 3 months which is necessary for monitoring and continuation of the contraceptive method. Choice D is not the correct answer because it shows the client's understanding of the potential delay in fertility after discontinuing Depo-Provera, which is an important aspect of the contraceptive method that the client should be aware of.