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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","C","D","F"]

Explanation

Rationale:
A. Fetal activity: Decreased fetal movement is an abnormal finding suggesting possible fetal distress or hypoxia. It indicates reduced oxygen or nutrient delivery to the fetus, often associated with maternal complications such as hypertension or preeclampsia. Immediate evaluation with fetal monitoring or ultrasound is warranted.

B. Urine ketones: The absence of urine ketones is expected and does not indicate a prenatal complication. Ketones would only be concerning if elevated, as they could signal dehydration, starvation, or poorly controlled diabetes, which is not present in this case.

C. Urine protein: The presence of 3+ protein in the urine is a key indicator of preeclampsia. Proteinuria results from endothelial damage in the kidneys caused by hypertension, leading to leakage of protein into the urine and confirming a serious pregnancy complication.

D. Report of headache: A severe, persistent headache unrelieved by acetaminophen suggests cerebral vasospasm related to preeclampsia. It reflects increased blood pressure affecting cerebral circulation and can precede seizures or eclampsia if untreated.

E. Respiratory rate: A respiratory rate of 16/min is within the normal range for adults and does not indicate a prenatal complication. There is no evidence of respiratory distress or metabolic abnormality in this finding.

F. Blood pressure: A reading of 162/112 mm Hg meets the diagnostic criteria for severe hypertension in pregnancy and strongly indicates preeclampsia. Uncontrolled elevated blood pressure increases the risk of seizures, placental abruption, and fetal growth restriction.

G. Gravida/parity: Being G3 P2 with one preterm birth is useful background information but not, by itself, a sign of a current complication. It helps identify obstetric history and risk factors but does not reflect an immediate prenatal concern in this assessment.

A. Advise the client to wait 1 hr before showering or swimming. B. Instruct the client to have his testosterone checked in 1 week. C. Wear clean gloves to apply the gel. D. Apply the gel to the client's genital region.

Correct Answer is A

Explanation

Rationale:
A. Advise the client to wait 1 hr before showering or swimming: Testosterone gel should be allowed to fully absorb into the skin before washing or swimming, typically waiting at least 1 hour. This ensures optimal absorption and therapeutic effect.

B. Instruct the client to have his testosterone checked in 1 week: Testosterone levels are generally evaluated after several weeks of therapy to assess effectiveness, not after just one week.

C. Wear clean gloves to apply the gel: The client should apply the medication themselves using clean, dry hands. The nurse should wear gloves only if assisting to prevent unintentional hormone absorption.

D. Apply the gel to the client's genital region: Testosterone gel should not be applied to the genitals due to increased absorption risk and skin irritation. Recommended sites include shoulders, upper arms, or abdomen.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is caring for a client who is pregnant. Exhibits The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

Correct Answer is ["A","C","D","F"]

Explanation

A nurse is preparing to administer testosterone gel to a client who has hypogonadism. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

The nurse is continuing to care for the client. Exhibits The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of posttraumatic stress disorder? (Select all that apply.)

The nurse is continuing to care for the client. Exhibits Which of the following conditions is the client is at greatest risk for developing? Select all that apply

A nurse is caring for a postpartum client in an outpatient setting. Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdown evidenced by the client's dropdown.

A home health nurse is planning care for a client who has right-sided weakness following a recent cerebrovascular accident. The client reports feeling unsteady when walking. Which of the following interventions should the nurse include?

A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

A nurse is reviewing the laboratory results for a female client who is receiving furosemide and digoxin. Which of the following findings should the nurse recognize increases the client's risk for developing digoxin toxicity?