A nurse is instructing a female client on how to check her basal body temperature to determine if she is ovulating. The nurse should instruct the client to check her temperature at which of the following times?
1 hour following intercourse
Every morning before arising
Before going to bed every night
On days 13 to 17 of her menstrual cycle
The Correct Answer is B
Choice A reason:
Checking basal body temperature 1 hour following intercourse is not recommended as a method to determine ovulation. Intercourse and physical activity can increase body temperature, which may lead to inaccurate readings. Basal body temperature should be measured after a period of rest, not after physical activity.
Choice B reason:
The basal body temperature method involves measuring the body's at-rest temperature to identify slight changes that occur around the time of ovulation. It is most accurate when taken every morning before getting out of bed, after at least 3 hours of uninterrupted sleep, and before any physical activity, including eating or drinking. A slight increase in basal body temperature typically occurs after ovulation and remains elevated until the next menstrual period. This method requires consistency and precise timing to be effective.
Choice C reason:
Measuring basal body temperature before going to bed every night is not an effective way to track ovulation. The body's temperature fluctuates throughout the day due to various factors, including activity levels, meals, and external temperatures. Therefore, nighttime measurements would not provide the consistent, resting temperature needed to accurately detect ovulation.
Choice D reason:
While it is true that ovulation typically occurs around the middle of the menstrual cycle, which for many women is between days 13 to 17, limiting temperature checks to these days only may miss the initial rise in temperature that indicates ovulation. Ovulation can vary from cycle to cycle, and it is important to measure basal body temperature daily to detect the pattern over time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Covering the cord with a sterile, moist saline dressing can help to maintain the cord's viability by preventing drying and possible infection. However, this action does not address the immediate concern of relieving pressure on the cord to restore fetal circulation.
Choice B reason:
Placing the client in the knee-chest position is the most immediate and critical action to take. This position helps to relieve pressure on the prolapsed cord, which is vital to prevent compression of the cord and maintain blood flow to the fetus. It is a recommended emergency intervention for umbilical cord prolapse.
Choice C reason:
Inserting a gloved hand into the vagina to relieve pressure on the cord is a measure that may be taken by a healthcare provider in the event of a cord prolapse. However, it is not the first action to be performed. The initial step is to change the mother's position to relieve pressure on the cord.
Choice D reason:
Preparing the client for an immediate birth is necessary because umbilical cord prolapse is an obstetric emergency that requires prompt delivery, often by cesarean section, to prevent fetal hypoxia. However, the very first action is to relieve pressure on the cord to restore fetal oxygenation while preparations for delivery are made.
Correct Answer is C
Explanation
Choice a reason:
Placing the client in the Trendelenburg position, which involves lying on the back with the feet higher than the head, is not indicated for the symptoms presented. This position is typically used to treat hypotension or improve venous return to the heart, not for respiratory depression or absent deep-tendon reflexes, which are signs of magnesium sulfate toxicity.
Choice b reason:
Assessing maternal blood glucose is important in the overall care of a preeclamptic patient, especially if there is a concern for gestational diabetes. However, it is not the immediate action required when a patient exhibits signs of magnesium sulfate toxicity, such as a respiratory rate of 10/min and absent deep-tendon reflexes.
Choice c reason:
Discontinuing the medication infusion is the correct action. A respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity. Immediate cessation of the drug is necessary to prevent further complications, such as respiratory depression or cardiac arrest. After stopping the infusion, the nurse should monitor the patient closely and prepare to administer calcium gluconate, the antidote for magnesium sulfate toxicity, if ordered by the physician.
Choice d reason:
Preparing for an emergency cesarean birth may be necessary if the fetus is in distress or if there are other obstetric indications. However, the information provided does not indicate fetal distress or an immediate need for delivery. The priority is addressing the signs of magnesium sulfate toxicity in the mother.
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