A nurse is providing care to a woman who is at 36 weeks of gestation and in preterm labor with ruptured membranes.The nurse determines that the client's oral temperature is 39.0 C (102.2 F). Besides notifying the provider, which of the following is an appropriate nursing action?

Administer prescribed antipyretics for maternal fever.

Prepare the client for emergency cesarean section.

Administer glucocorticoids intramuscularly.

Recheck the client's temperature in 4 hr.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Administering antipyretics for maternal fever is essential as elevated maternal temperatures can increase the risk of fetal tachycardia and potentially lead to fetal distress. Reducing fever promptly is a priority to stabilize both maternal and fetal conditions.

Choice B rationale

Preparing for an emergency cesarean section is not the immediate step for maternal fever; instead, managing the fever and assessing the need for further interventions based on the overall clinical picture should be prioritized.

Choice C rationale

Administering glucocorticoids is indicated for promoting fetal lung maturity in preterm labor, not specifically for maternal fever management. Fever management requires antipyretics and hydration.

Choice D rationale

Waiting 4 hours to recheck temperature delays prompt management, increasing risks for both the mother and fetus. Immediate action to reduce fever is crucial to prevent potential complications.

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Correct Answer is C

Explanation

Choice A rationale

Category 1 is a normal fetal heart rate pattern with no signs of fetal distress, which is not applicable in this case.

Choice B rationale

Category 2 represents an intermediate category with some concerns, but recurrent late decelerations and absent variability place this scenario in a higher risk category.

Choice C rationale

Category 3 indicates abnormal fetal heart rate patterns, including absent variability with recurrent late decelerations, which is associated with potential fetal hypoxia or acidemia and requires prompt intervention.

Choice D rationale

There is no Category 4 in fetal heart rate monitoring. .

A. Prolapsed cord. B. Abruptio placentae. C. Placenta previa. D. Incompetent cervix.

Correct Answer is B

Explanation

Choice A rationale

Prolapsed cord involves the umbilical cord descending into the birth canal ahead of the fetus, which is a critical emergency but presents differently, typically with changes in fetal heart rate and the cord being palpable or visible.

Choice B rationale

Abruptio placentae is characterized by the premature separation of the placenta from the uterine wall, which can cause severe abdominal pain, vaginal bleeding, and is a medical emergency requiring immediate intervention to prevent maternal and fetal complications.

Choice C rationale

Placenta previa involves the placenta partially or completely covering the cervical opening, which can cause painless vaginal bleeding but does not typically present with severe abdominal pain.

Choice D rationale

Incompetent cervix is associated with painless cervical dilation and potential preterm labor but not typically with severe abdominal pain and acute vaginal bleeding as seen with abruptio placentae.

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A nurse is providing care to a woman who is at 36 weeks of gestation and in preterm labor with ruptured membranes.The nurse determines that the client's oral temperature is 39.0 C (102.2 F). Besides notifying the provider, which of the following is an appropriate nursing action?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has preeclampsia.Suddenly, the client reports continuous severe abdominal pain and vaginal bleeding.The nurse should suspect which of the following complications?

Correct Answer is B

Explanation

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