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Matemity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy 44. Kerry, a 30-year-old G3 TPAL 0110 woman presents to the labor unit triage with complaints of lower abdominal cramping and urinary frequency at 30 week s* gestation. An appropriate nursing action would be to (select all that apply): a Assess the fetal heart rateb. Obtain urine for culture and sensitivityc. Assess Kerry's blood pressure and pulsed. Palpate Kerry's abdomen for contractions Maternal-Newbom Nursing: The Crtical Components Of Nursing Care, 3rd Edition, Roberta Durham, Linda Chapman ANS: a, b, dFeedback a. Women experiencing preterm labor may complain of back ache, pelvic aching, menstrual-lik e cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. The patient’s abdomen should be palpated to assess for contractions, and the fetus’s heart rate should be monitored.b. Women experiencing preterm labor may complain of back ache, pelvic aching, menstrual-lik e cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. A urinalysis and urine culture and sensitivity (C & S) should be obtained on all patients who present with signs of preterm labor, and the nurse must remember that signs of UTI often mimic normal pregnancy complaints (i.e., urgency, frequency). The patient’s abdomen should be palpated to assess for contractions, and the fetus’s heart rate should be monitored.c. Assessment of blood pressure and pulse is not an important nursing action in this scenario.d. Women experiencing preterm labor may complain of back ache, pelvic aching, menstrual-lik e cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. The patient’s abdomen should be palpated to assess for contractions and the fetus’s heart rate should be monitored. KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Moderate 45. The perinatal nurse k nows that tocolytic agents are most often used to (select all that apply): a Prevent maternal infectionb. Prolong pregnancy to 40 week s* gestationc. Prolong pregnancy to facilitate administration of antenatal corticosteroidsd. Allow for transport of the woman to a tertiary care facility Maternal-Newbom Nursing: The Critical Components Of Nursing Care, 3rd Edition, Roberta Durham, Linda Chapman ANS: ¢, dFeedback a. Tocolytics are not used to treat maternal infection.b. Tocolytics are generally only effective in delaying delivery for several days.c. Presently, it is believed that the best reason to use tocolytic drugs is to allow an opportunity to begin the administration of @ O 2