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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Use a cane for support while walking: A cane can enhance balance and reduce the risk of falls in clients with multiple sclerosis, who may experience muscle weakness, spasticity, or ataxia. It promotes mobility while maintaining safety in the home environment.
B. Avoid the use of orthotics: Orthotic devices, such as ankle-foot orthoses, can actually be helpful in improving gait and preventing foot drop. Advising against their use may deprive the client of important supportive tools.
C. Implement a rigorous range-of-motion exercise plan: While exercise is important, a rigorous plan may lead to fatigue and overheating, which can worsen MS symptoms. A gentle, balanced routine tailored to the client’s tolerance is safer.
D. Walk with feet close together for stability: Keeping the feet close together narrows the base of support and increases fall risk. A wider stance improves balance and stability, which is safer for ambulating clients with MS.
Correct Answer is D
Explanation
Rationale:
A. Diabetes screening: Screening for diabetes is a form of secondary prevention, aimed at early identification and intervention to prevent disease progression in asymptomatic individuals.
B. Nutrition counseling: Nutrition counseling is a primary prevention strategy when used to promote health and prevent disease. It aims to reduce risk factors before illness occurs.
C. Family planning: Family planning falls under primary prevention as it involves proactive measures to prevent unintended pregnancies and support reproductive health.
D. Physical therapy: Physical therapy is a tertiary prevention measure focused on reducing the impact of an existing disease or injury. It helps restore function, prevent further disability, and improve quality of life in individuals with chronic or advanced conditions.
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