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 A

Explanation

Choice A rationale

Uteroplacental insufficiency leads to late decelerations, which are characterized by a gradual decrease in fetal heart rate after the peak of a contraction. This indicates compromised blood flow between the uterus and placenta, affecting the fetus.

Choice B rationale

Umbilical cord compression usually causes variable decelerations, not late decelerations.

Choice C rationale

Maternal bradycardia does not cause changes in fetal heart rate patterns like late decelerations.

Choice D rationale

Fetal head compression causes early decelerations, which coincide with contractions, not late decelerations.

A. The fetal heartbeat can be heard via Doppler by 4 weeks of pregnancy. B. The fetal heartbeat can be heard by external Doppler around 10-12 weeks of pregnancy. C. You will first feel your baby move in week 24 of pregnancy. D. The heart formation begins in week 5 of pregnancy and we can hear it by Doppler at 6 weeks.

Correct Answer is B

Explanation

Choice A rationale

The fetal heartbeat cannot typically be heard via Doppler as early as 4 weeks of pregnancy. At this stage, the heart is still developing, and it is too soon for external detection with a Doppler device.

Choice B rationale

The fetal heartbeat is generally detectable by an external Doppler device around 10-12 weeks of pregnancy. This is the period when the heartbeat is strong enough to be picked up by the device.

Choice C rationale

Feeling the baby move, known as "quickening," typically occurs around 18-24 weeks of pregnancy, not 6 weeks. This sensation is different from hearing the heartbeat.

Choice D rationale

While the heart begins to form around week 5, it is not detectable by Doppler at 6 weeks. The technology does not have the sensitivity to detect such an early heartbeat externally.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is walking by a client's room and can hear the fetal heart rate dropping.The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Correct Answer is A

Explanation

A client, at 6 weeks gestation, arrives at the OB clinic for her initial visit and requests to hear the fetal heartbeat.What should the nurse include in the teaching regarding cardiac development?

Correct Answer is B

Explanation

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