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A 26 week G3 P2 has premature rupture of membranes. Which of the following orders would the nurse question?

Temperature q4 hours

Betamethasone 12.5mg q 24 hours × 2.

Apply external fetal monitor to assess contractions and fetal well-being.

Vaginal exam q 2 hours for labor progress.

Answer and Explanation

The Correct Answer is D

A. Regular temperature checks monitor for infection.

B. Betamethasone promotes fetal lung maturity.

C. Fetal monitoring is standard for assessing wellbeing.

D. Frequent vaginal exams increase infection risk and should be minimized

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Correct Answer is B

Explanation

A. Ignoring the mood swings is not an appropriate response because it may be a sign of postpartum mood changes that need to be monitored.

B. Mood swings in the postpartum period are common and often due to hormonal changes. This is normal unless it persists beyond two weeks, at which point it may indicate postpartum depression.

C. Suggesting antidepressants immediately is premature; mood swings are common in the postpartum period, and treatment is not necessary unless they persist or worsen.

D. Advising the husband to leave the wife unattended is unsafe and inappropriate. Ensuring the wife has support during this time is important.

A. The newborn sleeps for 6 consecutive hours during the night. B. The newborn breastfeeds every 4 to 5 hours for 5 minutes on each breast. C. The newborn has at least six to eight wet diapers per day. D. The newborn gains 1 to 2 ounces the first week.

Correct Answer is C

Explanation

A. Sleeping for 6 consecutive hours is not ideal for a 6-day-old newborn, as they should be feeding every 2-3 hours to maintain hydration and adequate nutrition.

B. Breastfeeding every 4 to 5 hours for 5 minutes per breast is too infrequent and brief for a newborn who should be feeding more often and for longer durations.

C. Six to eight wet diapers per day is a good indicator that the newborn is getting enough breast milk, as this indicates appropriate hydration and feeding.

D. Gaining 1 to 2 ounces the first week is below the expected rate of weight gain, which should typically be about 5-7 ounces per week for a newborn.

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A 26 week G3 P2 has premature rupture of membranes. Which of the following orders would the nurse question?

Nursing Test Bank

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