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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Your child can return to school once the fever has subsided.": The absence of fever does not indicate the child is no longer contagious. The child can still transmit the varicella-zoster virus until all lesions have crusted, even if fever has resolved.
B. "Your child can return to school after a negative titer result.": Titer testing is not used to determine contagiousness in active varicella infection. It is typically used to confirm immunity, especially after vaccination or past exposure.
C. "Your child can return to school once the lesions have crusted over.": Varicella is contagious until all lesions have crusted, which usually occurs about 5–7 days after the onset of rash. Crusting marks the end of the infectious period, making it safe for the child to return to school.
D. "Your child can return to school 24 hours after beginning antibiotics.": Varicella is a viral illness, not treated with antibiotics unless there is a secondary bacterial infection. Antibiotics do not impact the contagious period of the viral illness.
Correct Answer is D
Explanation
Rationale:
A. Self-mutilation: This behavior is more commonly associated with borderline personality disorder. Individuals with borderline traits may engage in self-harm as a means of emotional regulation or response to abandonment fears, not typical in antisocial personality disorder.
B. Social isolation: Clients with antisocial personality disorder are often socially manipulative and may actively engage with others for personal gain. They are typically not socially withdrawn but can be superficially charming and exploitative.
C. Paranoid ideation: Paranoia is more closely linked with paranoid or schizotypal personality disorders. While someone with antisocial traits may be suspicious if it serves their manipulative purposes, persistent paranoid ideation is not a defining feature.
D. Lack of empathy: A hallmark feature of antisocial personality disorder is a disregard for others' feelings, rights, and safety. These clients often exhibit a lack of remorse and empathy, making them prone to violating social norms and laws without guilt.
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