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. A client who has an open compound fracture of the humerus: This injury requires surgical intervention and has a moderate to high risk of complications. It is typically classified as yellow, indicating delayed care is acceptable but not minor.
B. A client who has multiple facial lacerations: These are superficial injuries that can be treated with simple wound care and suturing. The client is likely stable and ambulatory, fitting the criteria for a green tag, which denotes minor injuries requiring minimal care.
C. A client who has a puncture wound in the right lower lung: This suggests potential internal injury and respiratory compromise. Such a case is urgent and unstable, requiring immediate intervention, and would be tagged red for immediate treatment.
D. A client who has full-thickness burns over the lower extremities: Full-thickness burns covering a large area are life-threatening and resource-intensive to manage. Depending on the extent, this may fall under red or black, depending on survivability and available resources.
Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. Assess the client's lung sounds prior to the infusion: Pre-transfusion assessment of lung sounds is essential to detect any baseline abnormalities and to monitor for fluid overload or transfusion-related lung complications such as transfusion-associated circulatory overload.
B. Infuse the blood over 4 hr: Older adults are at increased risk for fluid overload, so transfusing packed RBCs slowly over 4 hours is appropriate and safer, as long as the blood is completely administered within the maximum 4-hour window from removal from refrigeration.
C. Verify with another nurse that the unit of blood is compatible with the client's blood type: A dual verification process is mandatory to ensure safe administration. The nurse must check the client’s ID, blood type, unit number, and expiration date with another licensed professional before initiating the transfusion.
D. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime and flush blood transfusion tubing. Hypotonic solutions like 0.45% sodium chloride can cause hemolysis and should never be used with blood products.
E. Don sterile gloves to prepare the blood administration setup: Sterile gloves are not necessary for setting up a blood transfusion. Clean gloves are sufficient for handling equipment and initiating IV therapy, following standard precautions.
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