A nurse is caring for a client who is 36 weeks of gestation and experiences a spontaneous rupture of membranes. Which of the following actions should the nurse take?
Administer magnesium sulfate to the client.
Administer betamethasone to the client.
Monitor the client's temperature every 2 hr.
Monitor fetal heart rate every 4 hr.
The Correct Answer is C
Rationale:
A. Administer magnesium sulfate to the client: Magnesium sulfate is typically used for neuroprotection before 32 weeks or to manage preeclampsia; it is not indicated for rupture of membranes at 36 weeks unless there are other risk factors.
B. Administer betamethasone to the client: Betamethasone is used to enhance fetal lung maturity, most beneficial before 34 weeks. At 36 weeks, the lungs are usually mature enough that corticosteroids are not routinely indicated.
C. Monitor the client's temperature every 2 hr: This helps detect early signs of chorioamnionitis, a serious infection risk after membrane rupture, especially with prolonged rupture.
D. Monitor fetal heart rate every 4 hr: Fetal heart monitoring should be more frequent in the presence of membrane rupture to promptly identify signs of distress or infection, not every 4 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. A small area rug is placed at the front door: Area rugs increase the risk of falls, especially in older adults or clients with mobility issues. Rugs should be removed or secured with non-slip backing to prevent tripping hazards at entrances and high-traffic areas.
B. The water heater is set at 54° C (129.2° F): This temperature is too high and poses a significant risk for burns or scalding. The recommended maximum water heater setting for safety is 49° C (120° F), especially in homes with children or older adults.
C. The batteries in the smoke alarms are changed annually: Changing smoke alarm batteries once a year aligns with fire safety recommendations. Functioning smoke alarms are a critical part of home safety and fire prevention.
D. A single light fixture hangs along the sidewalk to the house: One light may not provide adequate visibility, especially in poor weather or at night. Multiple, evenly spaced light sources are more effective for preventing trips or falls along walkways.
Correct Answer is B
Explanation
Rationale:
A. I should clean my stoma with moisturizing soap: Moisturizing soaps can leave a residue that interferes with the adhesive of the pouching system. The stoma area should be cleaned with warm water or a mild, non-moisturizing soap to ensure the pouch adheres properly.
B. I should cut my pouch opening 1/8 inch larger than my stoma: The opening should be just slightly larger than the stoma about 1/8 inch to prevent constriction while still protecting the surrounding skin from effluent and minimizing skin irritation.
C. I should expect my stoma to be blistered: A healthy stoma should appear moist, pink or red, and smooth. Blistering is a sign of skin breakdown or irritation and indicates improper pouch fitting or leakage, which requires intervention.
D. I should change my stoma pouch 30 minutes after heals: There isn't a specific 30-minute post-meal rule. The most important guideline for changing a pouch is when it's about one-third to one-half full, or if there is leakage or discomfort.
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