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 D

Explanation

A. "The test will be performed if your baby's heartbeat is heard."
Incorrect: Amniocentesis is not typically performed based on whether the baby's heartbeat is heard. It is done for specific diagnostic purposes, such as genetic testing or assessing certain fetal conditions.

B. "This test will determine if your baby's lungs are mature."
Incorrect: Amniocentesis does not determine fetal lung maturity. The test involves the extraction of a small amount of amniotic fluid to analyze fetal chromosomes and identify genetic conditions.

C. "After the test, you will be given Rh immune globulin since you are Rh positive."
Incorrect: Rh immune globulin (Rhogam) is given to Rhnegative pregnant women to prevent Rh sensitization, which occurs when an Rhnegative mother is exposed to
Rhpositive fetal blood. Rhogam is not directly related to amniocentesis.

D. "This test requires the presence of an adequate volume of amniotic fluid."
Correct: Amniocentesis requires a sufficient amount of amniotic fluid around the fetus for safe and accurate testing. If there is not enough amniotic fluid, the procedure may be postponed or canceled.

A. "I will monitor my weight gain during the remaining months." B. "I will use only nonprescription medications while pregnant." C. "I will tell my doctor before using home remedies for nausea." D. will reduce my stress level."

Correct Answer is B

Explanation

A. "I will monitor my weight gain during the remaining months."

Correct: Monitoring weight gain during pregnancy is an appropriate action as it helps to ensure the baby's growth and overall health.
B. "I will use only nonprescription medications while pregnant."

Incorrect: This statement indicates a need for further teaching. Nonprescription medications may not be safe during pregnancy, as some overthecounter drugs can potentially harm the
fetus. It's essential for pregnant women to consult their healthcare provider before taking any medications.
C. "I will tell my doctor before using home remedies for nausea."

Correct: This statement shows the client's understanding that it's important to consult with their healthcare provider before using any home remedies during pregnancy, as some
remedies may not be safe for the developing fetus.

D. "I will reduce my stress level."

Correct: Managing stress during pregnancy is beneficial for both the mother and the baby. It indicates a good understanding of selfcare during pregnancy.

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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 in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?

Correct Answer is D

Explanation

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is B

Explanation

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