A nurse is caring for a client who is at 37 weeks of gestation and experiences a spontaneous rupture of membranes before labor has begun. Which of the following actions should the nurse take?

Administer betamethasone to the client.

Administer magnesium sulfate to the client.

Monitor fetal heart rate every 4 hr.

Monitor the client's temperature every 2 hr.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Administer betamethasone to the client: Betamethasone is given to promote fetal lung maturity in preterm labor, typically before 34 weeks of gestation. At 37 weeks, the fetus is considered term, so corticosteroids are not indicated.

B. Administer magnesium sulfate to the client: Magnesium sulfate is used for neuroprotection in preterm labor or for seizure prophylaxis in preeclampsia. Since this client is at term without preeclampsia, magnesium sulfate is not indicated.

C. Monitor fetal heart rate every 4 hr: Continuous or frequent fetal heart rate monitoring is recommended after spontaneous rupture of membranes to detect signs of fetal distress or infection. Monitoring only every 4 hours is insufficient.

D. Monitor the client's temperature every 2 hr: Maternal infection, such as chorioamnionitis, is a significant risk after spontaneous rupture of membranes. Monitoring the client’s temperature every 2 hours allows early detection of infection and timely intervention.

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Correct Answer is A

Explanation

Rationale:
A. Serum albumin: Serum albumin is a key indicator of a client’s nutritional status, particularly protein intake and synthesis. Low albumin levels can reflect malnutrition, chronic illness, or liver dysfunction, while normal levels suggest adequate nutritional support and protein reserves.

B. Troponin level: Troponin is a cardiac biomarker used to diagnose myocardial injury or infarction. It is not related to nutrition and does not provide any information about the client’s dietary intake or protein status.

C. Serum sodium: Serum sodium reflects fluid and electrolyte balance rather than nutritional status. Abnormal sodium levels are typically associated with dehydration, fluid overload, or endocrine disorders, not with protein or calorie malnutrition.

D. Erythrocyte sedimentation rate: The erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and infection. It may rise with inflammatory conditions but does not provide direct information about a client’s nutritional health.

A. Prepare an IV bolus of dextrose 5% in water. B. Administer methylergonovine IM. C. Administer calcium gluconate IV. D. Position the client supine.

Correct Answer is C

Explanation

Rationale:
A. Prepare an IV bolus of dextrose 5% in water: Administering dextrose does not reverse magnesium sulfate toxicity. Dextrose primarily provides energy and fluid but has no effect on magnesium levels or neuromuscular function.

B. Administer methylergonovine IM: Methylergonovine is used to treat postpartum hemorrhage by promoting uterine contractions. It does not counteract magnesium toxicity and is unrelated to this emergency situation.

C. Administer calcium gluconate IV: Calcium gluconate is the antidote for magnesium sulfate toxicity. It works by antagonizing magnesium at neuromuscular junctions, reversing respiratory depression, hypotonia, and loss of deep tendon reflexes associated with toxicity.

D. Position the client supine: While client positioning may assist with comfort or circulation, supine positioning does not treat magnesium sulfate toxicity. The priority is administering the antidote to prevent further complications such as respiratory arrest.

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A nurse is caring for a client who is at 37 weeks of gestation and experiences a spontaneous rupture of membranes before labor has begun. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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