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 B
Explanation
Rationale:
A. Tenting skin turgor: Tenting indicates dehydration or fluid volume deficit, not overload. It reflects reduced skin elasticity due to poor interstitial fluid volume.
B. Respiratory rate 30/min: Tachypnea can result from pulmonary congestion or edema due to excess fluid in the intravascular space. It is a classic sign of fluid overload as the lungs struggle with impaired gas exchange.
C. Skin warm and dry: Warm, dry skin is a normal finding and does not suggest volume overload. Fluid retention typically causes edema or moist skin in severe cases.
D. Heart rate 60/min: A heart rate within normal range does not point to fluid overload. Often, fluid overload is associated with tachycardia due to increased preload and compensatory responses.
Correct Answer is C
Explanation
Rationale:
A. Contact the client's family to discuss the decision: While family members may be involved, the nurse must prioritize respecting the client’s autonomy. The client has expressed their wishes, and involving family without consent may violate confidentiality and autonomy.
B. Encourage the client to complete a final hemodialysis treatment: Pressuring or encouraging a client to undergo treatment they have refused especially when they have advance directives in place disregards their legal and ethical right to make decisions about their own care.
C. Discuss possible options for discharge with the client: Respecting the client’s decision and exploring care planning, such as hospice or palliative care services, is appropriate. This supports autonomy while ensuring comfort and dignity in the end-of-life process.
D. Discuss future treatment options with the client's health care surrogate: A surrogate decision-maker is only consulted when the client is unable to make decisions. In this case, the client is alert and capable, so the discussion should remain between the nurse and client.
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