Question

A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions?

Exhibit 1: Diagnostic Results​
Lecithin/sphingomyelin (L/S) ratio 1.4:1Phosphatidylglycerol (PG) absent ABO-Rh B-negative
Exhibit 2: Medication Administration Record​
Terbutaline 0.25 mg SQ every hr PRN contractions Rho(D) immune globulin 300 mcg IM once Nalbuphine 10 mg IV every 3 hr PRN pain
Exhibit 3: Progress Report
1655 - Amniocentesis completed, Toc transducer and external fetal monitor applied1700 - Fetal heart rate 130/min with moderate variability Uterine contractions q 5 to 8 min lasting 30 to 60 sec duration Uterine contractions palpated at 1+ intensity Client reports uterine contraction pain of 2 on a scale of 0 to 10
A. Administer terbutaline.
B. Discuss possible genetic anomalies with the client.
C. Administer nalbuphine.
D. Discontinue external fetal monitoring.

Answer 1

The nursing plan of care should A. administer terbutaline to suppress preterm labor, considering the potential risk of immature fetal lungs and Respiratory Distress Syndrome indicated by an L/S ratio of 1.4:1 and absent PG.

Step-by-step explanation:

Based on the information provided in the medical records, the nursing plan of care at 1800 for a client who is at 34 weeks of gestation should A. administer terbutaline.

The rationale behind this action is that the client has a documented Lecithin/sphingomyelin (L/S) ratio of 1.4:1 which suggests immature fetal lungs, and Phosphatidylglycerol (PG) is absent, indicating a risk of Respiratory Distress Syndrome (RDS) if delivered prematurely.

Terbutaline is a medication used to suppress preterm labor by relaxing the uterine muscles and decreasing the frequency and intensity of contractions, as mentioned in the Medication Administration Record.

The Progress Report indicates that the client is experiencing uterine contractions every 5 to 8 minutes, and thus, terbutaline is appropriate to help delay preterm labor.

It is also important to ensure continued fetal monitoring due to the uterine contractions and to assess the fetal response to treatment.