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 B

Explanation

A) The largest fetal diameter has passed through the pelvic outlet: This is an incorrect

interpretation of station 0. Station 0 means that the presenting part is at the level of the ischial spines, not fully descended through the pelvic outlet.

B) The lowermost portion of the presenting part is at the level of the ischial spines: This is the correct interpretation of station 0. Station 0 is the landmark at which the presenting part is at the level of the ischial spines in the maternal pelvis.
C) The posterior fontanel is palpable: The position of the fontanelle is not related to the station of the presenting part.
D) The fetal head is in the left occiput posterior position: The position of the fetal head is not indicated by the station measurement.

A. "It occurs during the first trimester and near the end of the pregnancy." B. "It's a minor inconvenience, which you should ignore." C. "There is no way to predict how long it will last in each individual client." D. "In most cases, it only lasts until the 12th week, but it will continue if you have poor bladder tone."

Correct Answer is A

Explanation

Choice A: Urinary frequency is a common symptom during pregnancy, especially in the first trimester and near the end of the pregnancy. During the first trimester, it is mainly due to

hormonal changes and increased blood flow to the pelvic area. In the later stages, it is caused by the growing uterus putting pressure on the bladder.

Choice B: Dismissing the client's concern as a minor inconvenience is not appropriate and may disregard the client's experience.

Choice C: While it is true that each individual client's experience may vary, it is important to provide the client with information regarding common patterns.

Choice D: Providing accurate information about the duration of urinary frequency is important. While it may last until the 12th week for many women, it does not continue throughout the entire pregnancy for most individuals, regardless of bladder tone.

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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 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?

Correct Answer is B

Explanation

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching?

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