A nurse is caring for a client who is at 37 weeks of gestation and experiences a spontaneous rupture of membranes before labor has begun. Which of the following actions should the nurse take?
Administer betamethasone to the client.
Administer magnesium sulfate to the client.
Monitor fetal heart rate every 4 hr.
Monitor the client's temperature every 2 hr.
The Correct Answer is D
Rationale:
A. Administer betamethasone to the client: Betamethasone is given to promote fetal lung maturity in preterm labor, typically before 34 weeks of gestation. At 37 weeks, the fetus is considered term, so corticosteroids are not indicated.
B. Administer magnesium sulfate to the client: Magnesium sulfate is used for neuroprotection in preterm labor or for seizure prophylaxis in preeclampsia. Since this client is at term without preeclampsia, magnesium sulfate is not indicated.
C. Monitor fetal heart rate every 4 hr: Continuous or frequent fetal heart rate monitoring is recommended after spontaneous rupture of membranes to detect signs of fetal distress or infection. Monitoring only every 4 hours is insufficient.
D. Monitor the client's temperature every 2 hr: Maternal infection, such as chorioamnionitis, is a significant risk after spontaneous rupture of membranes. Monitoring the client’s temperature every 2 hours allows early detection of infection and timely intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Advise the client to wait 1 hr before showering or swimming: Testosterone gel should be allowed to fully absorb into the skin before washing or swimming, typically waiting at least 1 hour. This ensures optimal absorption and therapeutic effect.
B. Instruct the client to have his testosterone checked in 1 week: Testosterone levels are generally evaluated after several weeks of therapy to assess effectiveness, not after just one week.
C. Wear clean gloves to apply the gel: The client should apply the medication themselves using clean, dry hands. The nurse should wear gloves only if assisting to prevent unintentional hormone absorption.
D. Apply the gel to the client's genital region: Testosterone gel should not be applied to the genitals due to increased absorption risk and skin irritation. Recommended sites include shoulders, upper arms, or abdomen.
Correct Answer is D
Explanation
Rationale:
A. Advise the adolescent to place the newborn for adoption: Suggesting adoption may be perceived as judgmental and does not address the adolescent’s immediate concern about accessing resources and caring for the baby.
B. Refer the adolescent to a local mental health clinic: While emotional support can be beneficial, referral to mental health services alone does not address practical concerns about affording and caring for the baby. Immediate assistance with resources is a priority.
C. Contact the adolescent's parent for assistance: Confidentiality and the adolescent’s autonomy must be respected unless there is a safety concern. The nurse should not contact parents without the adolescent’s consent.
D. Assist the adolescent in applying for Medicaid: Helping the adolescent apply for Medicaid directly addresses her concerns about affording prenatal care and infant needs. This action provides practical support, empowers her to access healthcare and resources, and promotes positive maternal and fetal outcomes.
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