A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?
Administer glucocorticoids intramuscularly.
Prepare the client for emergency cesarean section.
Assess the odor of the amniotic fluid.
Recheck the client's temperature in 4 hr.
The Correct Answer is C
A: Administering glucocorticoids intramuscularly is indicated for enhancing fetal lung maturity in cases of anticipated preterm birth. However, the client is at 38 weeks of gestation, which is not considered preterm, and the elevated temperature is the main concern.
B: Preparing the client for an emergency cesarean section based solely on an elevated temperature is not an appropriate action. There may be other factors contributing to the temperature elevation, and further assessment is needed.
C: An elevated temperature during pregnancy can indicate infection, which is a concern when the client's membranes have ruptured (premature rupture of membranes or PROM). Before any
interventions are initiated, the nurse should assess the odor of the amniotic fluid as it can provide important information about possible infection. If the amniotic fluid has a foul odor or appears
cloudy, it may indicate infection and require prompt medical attention.
D: Rechecking the client's temperature in 4 hours is not the appropriate immediate action when an elevated temperature is observed, especially in a pregnant woman.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Bowel prep protocols are not required for an amniocentesis procedure, as it involves sampling amniotic fluid from the uterus, not the bowel.
Choice B: Emptying the bladder before the procedure is important to improve comfort and minimize the risk of accidental puncture during the amniocentesis.
Choice C: It is essential to have a full bladder for some ultrasound procedures, but it is not necessary for an amniocentesis. A full bladder can help push the uterus upward and make it easier to visualize the fetus during the ultrasound, but it is not relevant to the amniocentesis procedure.
Choice D: Washing the abdomen with soap and water is not a required step for an amniocentesis procedure. The procedure involves sterile preparation of the abdomen using an antiseptic
solution.
Correct Answer is C
Explanation
A. "Increase your intake of ironrich foods and take a prenatal vitamin."
Important, but not directly related to reducing the risk of neural tube defects. Ironrich foods and prenatal vitamins are essential for overall maternal and fetal health, but they do not specifically target neural tube defect prevention.
B. "Avoid any alcohol consumption."
Important advice during pregnancy to prevent fetal alcohol spectrum disorders, but not directly related to reducing the risk of neural tube defects.
C. "Take a folic acid supplement for at least 3 months before you get pregnant."
Correct: Adequate folic acid intake before conception and during early pregnancy can significantly reduce the risk of neural tube defects in newborns.
D. "Avoid all foods containing aspartame."Aspartame is an artificial sweetener that has been studied for safety in pregnancy, and there is currently no strong evidence linking it to neural tube defects. However, it's still a good idea
to limit the intake of artificial sweeteners during pregnancy and focus on a balanced diet.
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