Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?
A. Administer glucocorticoids intramuscularly.
Administering glucocorticoids intramuscularly is indicated for enhancing fetal lung maturity in cases of anticipated preterm birth. However, the client is at 38 weeks of gestation, which is not considered preterm, and the elevated temperature is the main concern.
B. Prepare the client for emergency cesarean section.
Preparing the client for an emergency cesarean section based solely on an elevated temperature is not an appropriate action. There may be other factors contributing to the temperature elevation, and further assessment is needed.
C. Assess the odor of the amniotic fluid.
An elevated temperature during pregnancy can indicate infection, which is a concern when the client's membranes have ruptured (premature rupture of membranes or PROM). Before anyinterventions are initiated, the nurse should assess the odor of the amniotic fluid as it can provide important information about possible infection. If the amniotic fluid has a foul odor or appearscloudy, it may indicate infection and require prompt medical attention.
D. Recheck the client's temperature in 4 hr.
Rechecking the client's temperature in 4 hours is not the appropriate immediate action when an elevated temperature is observed, especially in a pregnant woman.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternity Exam - Proctored Exam 2. Take the full exam now
Full Explanation
A: Administering glucocorticoids intramuscularly is indicated for enhancing fetal lung maturity in cases of anticipated preterm birth. However, the client is at 38 weeks of gestation, which is not considered preterm, and the elevated temperature is the main concern.
B: Preparing the client for an emergency cesarean section based solely on an elevated temperature is not an appropriate action. There may be other factors contributing to the temperature elevation, and further assessment is needed.
C: An elevated temperature during pregnancy can indicate infection, which is a concern when the client's membranes have ruptured (premature rupture of membranes or PROM). Before any
interventions are initiated, the nurse should assess the odor of the amniotic fluid as it can provide important information about possible infection. If the amniotic fluid has a foul odor or appears
cloudy, it may indicate infection and require prompt medical attention.
D: Rechecking the client's temperature in 4 hours is not the appropriate immediate action when an elevated temperature is observed, especially in a pregnant woman.
Similar Questions
A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?
A. "You can continue your moderate daily jogging as long as you stay hydrated, don't push yourself too hard, and don't get overheated."
Engaging in moderate physical activity during pregnancy, such as jogging, is generally safe and beneficial for pregnant women who have uncomplicated pregnancies. Staying hydrated, avoiding excessive exertion, and preventing overheating are important considerations during exercise.
B. "Activities that consistently raise your body temperature, such as saunas and hot tubs, are safe until the third trimester."
The use of saunas and hot tubs during pregnancy is generally not recommended at any trimester, as they can cause hyperthermia and pose risks to the developing fetus.
C. "It is recommended that pregnant clients limit their exercise to only stretching while lying flat on a mat several times a week."
Limiting exercise to only stretching on a mat is not appropriate during pregnancy. Regular physical activity is generally encouraged, provided there are no specific contraindications or complications.
D. "Exercising during pregnancy is not recommended at all."
Completely avoiding exercise during pregnancy is not recommended, as moderate and appropriate physical activity can have various benefits for both the mother and the baby.
Full Explanation
A: Engaging in moderate physical activity during pregnancy, such as jogging, is generally safe and beneficial for pregnant women who have uncomplicated pregnancies. Staying hydrated, avoiding excessive exertion, and preventing overheating are important considerations during exercise.
B: The use of saunas and hot tubs during pregnancy is generally not recommended at any trimester, as they can cause hyperthermia and pose risks to the developing fetus.
C: Limiting exercise to only stretching on a mat is not appropriate during pregnancy. Regular physical activity is generally encouraged, provided there are no specific contraindications or complications.
D: Completely avoiding exercise during pregnancy is not recommended, as moderate and appropriate physical activity can have various benefits for both the mother and the baby.
A nurse in the emergency department is admitting a client who is experiencing an especially rapid labor (precipitous labor). She is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head crowning. The client tells the nurse she feels a strong urge to push. Which of the following instructions should the nurse make to help the mother have a more controlled birth?
A. "You should take a deep, cleansing breath and breathe naturally."
Taking deep, cleansing breaths and breathing naturally is not the appropriate technique during the crowning phase of labor, as it can increase the risk of rapid birth and potential perinealtrauma.
B. "You should go ahead and push as hard as you can to assist the delivery."
In the case of precipitous labor, actively pushing as hard as possible can increase the risk of rapid birth and potential complications for both the mother and the baby.
C. "You should try to blow or pant as the baby is being born to help avoid a toorapid birth."
During a precipitous labor with the baby's head crowning, the nurse should encourage themother to perform blowing or panting breaths during contractions. This technique helps to slow down the delivery process and allows the perineum to stretch gradually, reducing the risk of tearing or other trauma.
D. "You should try to perform slowpaced breathing patterns."
Slowpaced breathing patterns are not recommended during the crowning phase of labor, as they may not effectively control the birth process.
Full Explanation
A: Taking deep, cleansing breaths and breathing naturally is not the appropriate technique during the crowning phase of labor, as it can increase the risk of rapid birth and potential perineal trauma.
C: During a precipitous labor with the baby's head crowning, the nurse should encourage the mother to perform blowing or panting breaths during contractions. This technique helps to slow down the delivery process and allows the perineum to stretch gradually, reducing the risk of tearing or other trauma.
B: In the case of precipitous labor, actively pushing as hard as possible can increase the risk of rapid birth and potential complications for both the mother and the baby.
D: Slowpaced breathing patterns are not recommended during the crowning phase of labor, as they may not effectively control the birth process.
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
A. Fetal head compression
Fetal head compression: Fetal head compression would typically result in variable decelerations, not late decelerations.
B. Umbilical cord compression
Umbilical cord compression: Umbilical cord compression is associated with variable decelerations, not late decelerations.
C. Uteroplacental insufficiency
Uteroplacental insufficiency: Late decelerations occur due to decreased blood flow and oxygen supply to the fetus, which can be caused by uteroplacental insufficiency. This condition can lead to fetal hypoxia during contractions.
D. Maternal bradycardia
Maternal bradycardia: Maternal bradycardia would not directly cause late decelerations in the fetal heart rate.
Full Explanation
A) Fetal head compression: Fetal head compression would typically result in variable decelerations, not late decelerations.
B) Umbilical cord compression: Umbilical cord compression is associated with variable decelerations, not late decelerations.
C) Uteroplacental insufficiency: Late decelerations occur due to decreased blood flow and oxygen supply to the fetus, which can be caused by uteroplacental insufficiency. This condition can lead to fetal hypoxia during contractions.
D) Maternal bradycardia: Maternal bradycardia would not directly cause late decelerations in the fetal heart rate.