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A nurse is providing care to a woman who is at 36 weeks of gestation and in preterm labor with ruptured membranes.
The nurse determines that the client's oral temperature is 39.0 C (102.2 F). Besides notifying the provider, which of the following is an appropriate nursing action?

A.

Administer prescribed antipyretics for maternal fever.

B.

Prepare the client for emergency cesarean section.

C.

Administer glucocorticoids intramuscularly.

D.

Recheck the client's temperature in 4 hr.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Administering antipyretics for maternal fever is essential as elevated maternal temperatures can increase the risk of fetal tachycardia and potentially lead to fetal distress. Reducing

fever promptly is a priority to stabilize both maternal and fetal conditions.

 

Choice B rationale

Preparing for an emergency cesarean section is not the immediate step for maternal fever; instead, managing the fever and assessing the need for further interventions based on the

overall clinical picture should be prioritized.

 

Choice C rationale

Administering glucocorticoids is indicated for promoting fetal lung maturity in preterm labor, not specifically for maternal fever management. Fever management requires antipyretics

and hydration.

 

Choice D rationale

Waiting 4 hours to recheck temperature delays prompt management, increasing risks for both the mother and fetus. Immediate action to reduce fever is crucial to prevent potential

complications.


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Sneezing is a reflex action to clear the nasal passages and is not a feeding cue. It does not indicate hunger but is more likely related to environmental irritants or the baby adjusting to breathing air.

Choice B rationale

Moving legs in a bicycle motion is a common newborn reflex that is associated with general activity or discomfort, rather than a specific signal of hunger. This movement is typically seen during periods of wakefulness or while the baby is trying to soothe themselves.

Choice C rationale

Putting their hand to their mouth is a well-recognized hunger cue in newborns. This behavior often precedes crying and indicates that the baby is ready to feed. It's a self-soothing mechanism that also signals hunger.

Choice D rationale

Extending both arms to the side of their body is more related to the Moro reflex, which is a startle reflex in response to a sudden movement or noise. It is not associated with feeding cues or hunger.

Correct Answer is A

Explanation

Choice A rationale

Brisk patellar deep tendon reflexes can indicate central nervous system irritability, which might suggest conditions like preeclampsia or eclampsia if accompanied by other symptoms. It's critical to assess and monitor for further complications.

Choice B rationale

A moderate amount of lochia on the perineal pad over 2 hours is normal postpartum bleeding and does not typically indicate an immediate concern if within expected ranges.

Choice C rationale

A fundus at the level of the umbilicus is an expected finding 4 hours postpartum and indicates normal uterine involution. It is not a priority concern at this stage.

Choice D rationale

Approximated edges of an episiotomy indicate that the incision is healing properly without signs of infection or dehiscence. This is a normal and expected finding in the postpartum period.

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