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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "Schedule rest periods during the day.": Fatigue is a common symptom of multiple sclerosis. Scheduling rest periods helps conserve energy, prevent exacerbation of symptoms, and improve overall functioning without overtaxing the client.
B. "Soak in a hot bath.": Heat can worsen multiple sclerosis symptoms by temporarily increasing nerve conduction delays. Hot baths may trigger fatigue or weakness and are generally discouraged.
C. "Perform aerobic activities three times per week.": While gentle exercise is beneficial, intense aerobic activity can exacerbate fatigue and heat sensitivity in clients with multiple sclerosis. Exercise should be balanced with rest periods.
D. "Have your partner complete activities of daily living for you.": Encouraging total dependence can reduce independence and self-efficacy. Clients should perform activities within their capacity to maintain function while pacing themselves appropriately.
Correct Answer is B
Explanation
Rationale:
A. The client exhibits a flat affect: A flat affect reflects blunted emotional expression and is typically a symptom of depression. Its persistence suggests the condition has not yet improved.
B. The client can express angry feelings: The ability to identify and express emotions, including anger, indicates improved emotional responsiveness and progress in managing depressive symptoms. This reflects increased insight and healthier coping.
C. The client experiences self-doubt when making decisions: Persistent self-doubt is a common feature of depression and suggests that the client still struggles with confidence and decision-making.
D. The client looks down when speaking to others: Avoiding eye contact and looking down are associated with low self-esteem and social withdrawal, which are characteristic of depression and indicate the condition is not yet improving.
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