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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Position the client on her side: Late decelerations are often associated with uteroplacental insufficiency, which may be improved by changing the maternal position to improve blood flow to the placenta.
B. Elevate the client's legs: Elevating the client's legs would not directly address the cause of late decelerations.
C. Increase the infusion rate of the IV fluid: While ensuring adequate hydration is important, it is not the priority action when late decelerations are noted.
D. Administer oxygen via a face mask: Oxygen administration may be necessary, but it is not the priority action. Positioning the client on her side to improve blood flow is the priority.
Correct Answer is B
Explanation
A. Maintain the client in the lithotomy position: The lithotomy position is not typically
maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B. Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C. Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D. Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.
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