A nurse admits a woman who is 38 weeks gestation and has ruptured membranes.
The nurse determines that the amniotic fluid is clear and odorless.
Besides notifying the provider, which of the following is the appropriate first nursing action?
Allow the client to ambulate in the hallway to initiate labor.
Encourage oral fluids and administer an antipyretic medication.
Administer glucocorticoids intramuscularly.
Check the client's temperature every 2 hours.
The Correct Answer is D
Choice A rationale
Allowing the client to ambulate in the hallway to initiate labor is not the first appropriate action because it does not address the immediate need to monitor the client's temperature. Ambulation can be considered after ensuring there are no signs of infection or other complications.
Choice B rationale
Encouraging oral fluids and administering an antipyretic medication is not the initial priority. While hydration is important, the primary focus should be on monitoring for signs of infection, which can be indicated by changes in temperature.
Choice C rationale
Administering glucocorticoids intramuscularly is typically for promoting fetal lung maturity in cases of preterm labor, not for term pregnancies at 38 weeks. It does not address the immediate need to monitor maternal temperature after membrane rupture.
Choice D rationale
Checking the client's temperature every 2 hours is crucial to monitor for signs of infection, such as chorioamnionitis, which can occur after membrane rupture. Early detection of fever can prevent complications for both mother and baby.
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The nurse should prioritize administering magnesium sulfate and monitoring for signs of magnesium toxicity.
- Administering magnesium sulfate: This is crucial for preventing seizures in patients with preeclampsia, given her symptoms and elevated blood pressure.
- Monitoring for signs of magnesium toxicity: Essential when administering magnesium sulfate, as it can have serious side effects.
Correct Answer is D
Explanation
Choice A rationale
A post-term pregnancy at 42 weeks of gestation does not require tocolytic therapy. Tocolytics are used to stop preterm labor, not to manage full-term or post-term pregnancies.
Choice B rationale
A client who is dilated to 7 cm and experiencing contractions every 3-4 minutes is in active labor, and tocolytic therapy is not appropriate in this advanced stage of labor.
Choice C rationale
Braxton-Hicks contractions at 36 weeks of gestation are typically harmless and do not require tocolytic therapy. These contractions are usually irregular and do not lead to labor.
Choice D rationale
A client who is experiencing preterm labor at 32 weeks of gestation is an appropriate candidate for tocolytic therapy. The goal is to delay labor to allow for further fetal development and possibly administer corticosteroids to enhance fetal lung maturity.
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