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.

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Correct Answer is C

Explanation

A. "Increase your intake of ironrich foods and take a prenatal vitamin."
Important, but not directly related to reducing the risk of neural tube defects. Ironrich foods and prenatal vitamins are essential for overall maternal and fetal health, but they do not specifically target neural tube defect prevention.
B. "Avoid any alcohol consumption."
Important advice during pregnancy to prevent fetal alcohol spectrum disorders, but not directly related to reducing the risk of neural tube defects.
C. "Take a folic acid supplement for at least 3 months before you get pregnant."
Correct: Adequate folic acid intake before conception and during early pregnancy can significantly reduce the risk of neural tube defects in newborns.
D. "Avoid all foods containing aspartame."Aspartame is an artificial sweetener that has been studied for safety in pregnancy, and there is currently no strong evidence linking it to neural tube defects. However, it's still a good idea
to limit the intake of artificial sweeteners during pregnancy and focus on a balanced diet.

A. The presenting part is 1 cm above the ischial spines. B. The cervix is effaced 1 cm. C. The cervix is 1 cm dilated. D. The presenting part is 1 cm below the ischial spines.

Correct Answer is C

Explanation

The correct answer is: c. The cervix is 1 cm dilated.

Choice A reason:

The presenting part is 1 cm above the ischial spines. This statement would be documented as -1 station. Fetal station is measured in centimeters relative to the ischial spines, with negative numbers indicating the presenting part is above the spines.

Choice B reason:

The cervix is effaced 1 cm. Effacement is measured in percentages, not centimeters. It refers to the thinning of the cervix, which progresses from 0% (not effaced) to 100% (fully effaced).

Choice C reason:

The cervix is 1 cm dilated. This means the cervix has opened 1 cm, which is a common measurement during early labor. Cervical dilation ranges from 0 cm (closed) to 10 cm (fully dilated).

Choice D reason:

The presenting part is 1 cm below the ischial spines. This would be documented as +1 station. Positive numbers indicate the presenting part is below the ischial spines, moving towards delivery.

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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 instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider, which is documented as: 1. Which of the following interpretations of this finding should the nurse make?

Correct Answer is C

Explanation

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A nurse is caring for a client who is in the first stage of labor and is using patternpaced breathing. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

A nurse is admitting a client who is at 38 weeks of gestation and is in the active phase of the first stage of labor. Which of the following assessment findings is the first priority for the nurse to report to the provider?

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