A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

Administer glucocorticoids intramuscularly.

Prepare the client for emergency cesarean section.

Assess the odor of the amniotic fluid.

Recheck the client's temperature in 4 hr.

Answer and Explanation

The Correct Answer is C

A: Administering glucocorticoids intramuscularly is indicated for enhancing fetal lung maturity in cases of anticipated preterm birth. However, the client is at 38 weeks of gestation, which is not considered preterm, and the elevated temperature is the main concern.
B: Preparing the client for an emergency cesarean section based solely on an elevated temperature is not an appropriate action. There may be other factors contributing to the temperature elevation, and further assessment is needed.

C: An elevated temperature during pregnancy can indicate infection, which is a concern when the client's membranes have ruptured (premature rupture of membranes or PROM). Before any
interventions are initiated, the nurse should assess the odor of the amniotic fluid as it can provide important information about possible infection. If the amniotic fluid has a foul odor or appears
cloudy, it may indicate infection and require prompt medical attention.

D: Rechecking the client's temperature in 4 hours is not the appropriate immediate action when an elevated temperature is observed, especially in a pregnant woman.

Nursing Test Bank

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Correct Answer is ["B","E"]

Explanation

Choice A: Amniocentesis is not primarily performed to determine the gender of the fetus. The main indication for this procedure is to detect genetic abnormalities or chromosomal disorders.
Choice B: The primary purpose of an amniocentesis is to detect chromosomal abnormalities such as Down syndrome (trisomy 21), trisomy 18, and trisomy 13, among others.
Choice C: Rh incompatibility is assessed through blood tests, not amniocentesis. It involves determining the Rh factor of the mother's blood and monitoring for potential Rh sensitization.

Choice D: Cephalopelvic disproportion refers to a situation where the baby's head is too large or the mother's pelvis is too small to allow for a vaginal delivery. It is not related to amniocentesis.
Choice E: While detecting neural tube defects can be done through amniocentesis, it is not the primary indication for the procedure. Neural tube defects can also be screened for through blood tests and ultrasound examinations. Amniocentesis is more commonly used for chromosomal analysis.

A. Quickening B. Ballottement C. Chloasma D. Lightening

Correct Answer is A

Explanation

A) Quickening: Quickening is the term used to describe the first perception of fetal movements by the pregnant woman. It typically occurs between 16 to 20 weeks of gestation, which aligns with the client's statement about feeling fluttering movements at 18 weeks.
B) Ballottement: Ballottement is a physical examination technique performed by a healthcare provider to assess the fetus's position in the uterus. It is not related to the client's perception of fetal movement.
C) Chloasma: Chloasma refers to hyperpigmented skin areas that can appear during pregnancy due to hormonal changes. It is not related to fetal movement.
D) Lightening: Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs in the third trimester. It is not related to the feeling of fetal movements by the mother.

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A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is at 18 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?

Correct Answer is A

Explanation

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