A nurse is caring for a 32-year-old female client who is at 36 weeks of gestation in the labor and delivery unit.
The nurse should monitor the client’s
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
The nurse should monitor the client’s temperature due to the risk of chorioamnionitis.
Rationale for correct answers
Temperature monitoring is crucial for detecting chorioamnionitis, an infection of the amniotic sac, which is a major risk following preterm premature rupture of membranes (PPROM). PPROM increases susceptibility to ascending bacterial infection, leading to inflammation. Fever (>38°C or 100.4°F) is a primary diagnostic criterion.
Chorioamnionitis presents with maternal fever, fetal tachycardia (>160/min), uterine tenderness, and foul-smelling amniotic fluid. The client's normal temperature now (36.7°C) requires ongoing monitoring, as infection could develop rapidly.
Rationale for incorrect Response 1 options
- Magnesium levels: Magnesium sulfate is used for seizure prophylaxis in eclampsia or for neuroprotection in preterm labor. This client has no signs of either condition.
- Fundal height: Measurement assesses fetal growth and amniotic fluid levels; it is not a direct indicator of infection risk.
- Clotting factors: No evidence of coagulopathy or bleeding abnormalities; coagulation profile is normal.
Rationale for incorrect Response 2 options
- Concealed hemorrhage: No signs of placental abruption (painful bleeding, rigid abdomen). Normal hemoglobin (12.0 g/dL) supports this.
- Seizures: No hypertensive crisis or neurological symptoms suggestive of eclampsia.
- Disseminated intravascular coagulation (DIC): No abnormal coagulation markers or evidence of excessive bleeding.
Take-home points
• PPROM increases the risk of chorioamnionitis, a serious intrauterine infection. • Fever monitoring is essential, as maternal fever is an early indicator of infection. • Antibiotics are given prophylactically to reduce chorioamnionitis risk in PPROM. • Differentiation from placental abruption, eclampsia, and DIC is based on clinical and laboratory findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The stepping reflex, also known as the walking or dancing reflex, is elicited by holding the infant upright with their feet touching a flat surface. The infant will make stepping or dancing movements. This is not elicited by stroking the lateral sole of the foot.
Choice B rationale
The Babinski reflex is elicited by stroking the lateral sole of the infant's foot from the heel upward and across the ball of the foot. A positive Babinski sign is characterized by dorsiflexion of the great toe and fanning out of the other toes. This reflex is normal in infants and typically disappears by 12 to 24 months of age.
Choice C rationale
The tonic neck reflex, also known as the fencing reflex, is elicited by turning the infant's head to one side. The arm and leg on the turned side extend, while the arm and leg on the opposite side flex. Stroking the sole of the foot does not elicit this reflex.
Choice D rationale
The plantar grasp reflex is elicited by placing a finger or object across the base of the infant's toes. The toes will curl downward and grasp the object. This reflex is different from the response elicited by stroking the lateral sole of the foot. .
Correct Answer is B
Explanation
Choice A rationale
Thoroughly cooking meat to an internal temperature of 160°F (71°C) kills the Toxoplasma gondii parasite, thus preventing transmission through ingestion of contaminated meat. This is a crucial preventive measure recommended for pregnant women.
Choice B rationale
Drinking unpasteurized milk poses a risk of toxoplasmosis, as well as other foodborne illnesses like listeriosis and brucellosis. Pasteurization is a process that heats milk to a specific temperature for a set time, killing harmful bacteria and parasites, including Toxoplasma gondii. Therefore, this statement indicates a need for further instruction, as pregnant women should consume only pasteurized dairy products.
Choice C rationale
Cat feces can contain oocysts of Toxoplasma gondii, which can become infectious after a period of sporulation. Avoiding contact with materials possibly contaminated with cat feces, such as litter boxes and garden soil, is an important measure to prevent toxoplasmosis.
Choice D rationale
Handling raw meat can expose a person to Toxoplasma gondii cysts. Avoiding touching mucous membranes of the mouth or eyes after handling raw meat and washing hands thoroughly reduces the risk of self-inoculation with the parasite.
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