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) absentABO-Rh B-negative
Exhibit 2: Medication Administration Record​
Terbutaline 0.25 mg SQ every hr PRN contractionsRho(D) immune globulin 300 mcg IM onceNalbuphine 10 mg IV every 3 hr PRN pain
Exhibit 3: Progress Report
1655 - Amniocentesis completed, tocotransducer and external fetal monitor applied1700 - Fetal heart rate 130/min with moderate variabilityUterine contractions q 5 to 8 min lasting 30 to 60 sec durationUterine contractions palpated at 1+ intensityClient 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 nurse's care plan at 34 weeks gestation should include administering terbutaline to manage preterm labor contractions due to the immature L/S ratio and absence of PG, which are indicative of undeveloped fetal lungs.

Step-by-step explanation:

The nursing plan of care should include administering terbutaline. The L/S ratio of 1.4:1 indicates immature lungs, and since phosphatidylglycerol (PG) is absent, the fetus's lungs may not be mature enough for adequate gas exchange. Terbutaline, a tocolytic medication, is used to halt preterm labor by relaxing the uterine muscles, thereby preventing contractions and potentially delaying birth to allow for further fetal lung development.

Given that the client is at 34 weeks of gestation and is experiencing uterine contractions, terbutaline can provide the necessary intervention to manage these contractions. Furthermore, as the client is ABO-Rh B-negative, Rho(D) immune globulin has likely been administered to prevent Rh sensitization.