A nurse is caring for a client who is 36 weeks of gestation and experiences a spontaneous rupture of membranes. Which of the following actions should the nurse take?

Administer magnesium sulfate to the client.

Administer betamethasone to the client.

Monitor the client's temperature every 2 hr.

Monitor fetal heart rate every 4 hr.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Administer magnesium sulfate to the client: Magnesium sulfate is typically used for neuroprotection before 32 weeks or to manage preeclampsia; it is not indicated for rupture of membranes at 36 weeks unless there are other risk factors.

B. Administer betamethasone to the client: Betamethasone is used to enhance fetal lung maturity, most beneficial before 34 weeks. At 36 weeks, the lungs are usually mature enough that corticosteroids are not routinely indicated.

C. Monitor the client's temperature every 2 hr: This helps detect early signs of chorioamnionitis, a serious infection risk after membrane rupture, especially with prolonged rupture.

D. Monitor fetal heart rate every 4 hr: Fetal heart monitoring should be more frequent in the presence of membrane rupture to promptly identify signs of distress or infection, not every 4 hours.

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Correct Answer is C

Explanation

Rationale:

A. Auscultation: This step is performed after inspection and before percussion or palpation to avoid altering bowel sounds. It allows the nurse to assess for the presence, frequency, and character of bowel sounds without stimulating them artificially.

B. Inspection: This is the first step in the abdominal assessment. It involves visually examining the abdomen for contour, symmetry, skin changes, pulsations, or visible masses without touching the patient, helping establish a baseline.

C. Palpation: Palpation is the final step in abdominal assessment to prevent interference with bowel sounds. It allows the nurse to detect tenderness, masses, or organ enlargement, but should only be done after auscultation and percussion.

D. Percussion: This is done after auscultation and provides information on underlying structures, such as gas, fluid, or masses. It helps differentiate between dullness, resonance, or tympany across abdominal quadrants.

A. "Attempt to void every 2 hours." B. "Perform Kegel exercises several times daily." C. "Maintain a daily fluid intake of 1,000 to 1,200 mL/day." D. "Take prescribed diuretics no later than 2000." E. "Maintain optimal body weight for height."

Correct Answer is ["A","B","E"]

Explanation

Rationale:

A. "Attempt to void every 2 hours.": Scheduled voiding helps reduce the likelihood of bladder overfilling and decreases episodes of leakage, especially in stress incontinence where physical pressure causes urine loss.

B. "Perform Kegel exercises several times daily.": Kegel exercises strengthen the pelvic floor muscles, which support the bladder and urethra. Regular practice improves muscle tone and helps control urine leakage during activities like coughing or sneezing.

C. "Maintain a daily fluid intake of 1,000 to 1,200 mL/day.": Limiting fluids excessively can lead to concentrated urine and bladder irritation, increasing urgency and risk of infection. A moderate, well-balanced intake closer to 1,500–2,000 mL/day is generally recommended.

D. "Take prescribed diuretics no later than 2000.": While relevant for fluid management, it's not a direct or primary instruction specifically for treating or managing stress incontinence itself. Diuretics increase urine production, which could potentially worsen incontinence.

E. "Maintain optimal body weight for height.": Excess weight increases abdominal pressure on the bladder, worsening stress incontinence. Achieving and maintaining a healthy weight can reduce symptoms and support pelvic muscle strength.

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A nurse is caring for a client who is 36 weeks of gestation and experiences a spontaneous rupture of membranes. Which of the following actions should the nurse take?

Nursing Test Bank

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