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 D
Explanation
Rationale:
A. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to avoid reaching over and contaminating the sterile field. Opening toward the body risks touching or dropping contaminants onto the field.
B. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Sterile items should be dropped from a minimal height, close to the field, to prevent them from bouncing, falling off, or becoming contaminated. A 10-inch drop increases the risk of contamination.
C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 1 inch (2.5 cm) of a sterile field is considered contaminated, not just 0.5 inches. Placing objects inside only 0.5 in does not guarantee sterility and may result in contamination.
D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: Keeping the bottle outside the sterile field prevents contamination from the outside of the bottle. Only the sterile contents should enter the sterile container, maintaining the integrity of the sterile field during the dressing change.
Correct Answer is D
Explanation
Rationale:
A. "Your child can return to school 24 hours after beginning antibiotics.": Varicella (chickenpox) is a viral infection, so antibiotics are not effective unless there is a secondary bacterial infection.
B. "Your child can return to school once the fever has subsided.": Although the fever may resolve, the child remains contagious until all lesions have crusted over, so returning at this stage risks spreading infection.
C. "Your child can return to school after a negative titer result.": Titer testing is used to assess immunity, not for determining when an active infection is no longer contagious.
D. "Your child can return to school once the lesions have crusted over.": This is the correct statement because a child with varicella is contagious until all vesicular lesions have dried and crusted, usually about 5–7 days after onset.
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