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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 B

Explanation

Choice A rationale

Prolapsed cord involves the umbilical cord descending into the birth canal ahead of the fetus, which is a critical emergency but presents differently, typically with changes in fetal

heart rate and the cord being palpable or visible.

Choice B rationale

Abruptio placentae is characterized by the premature separation of the placenta from the uterine wall, which can cause severe abdominal pain, vaginal bleeding, and is a medical

emergency requiring immediate intervention to prevent maternal and fetal complications.

Choice C rationale

Placenta previa involves the placenta partially or completely covering the cervical opening, which can cause painless vaginal bleeding but does not typically present with severe

abdominal pain.

Choice D rationale

Incompetent cervix is associated with painless cervical dilation and potential preterm labor but not typically with severe abdominal pain and acute vaginal bleeding as seen with

abruptio placentae

Correct Answer is C

Explanation

Choice A rationale

Accelerations are increases in the fetal heart rate (FHR) above the baseline, typically in response to fetal movement or uterine contractions. They indicate a healthy, well-oxygenated

fetus and are not consistent with the described pattern of decelerations.

Choice B rationale

Late decelerations are characterized by a gradual decrease in FHR that begins after the contraction has started, with the lowest point of the deceleration (nadir) occurring after the

peak of the contraction. They are associated with uteroplacental insufficiency and fetal hypoxia, which is not described in the scenario.

Choice C rationale

Early decelerations are a gradual decrease in FHR that mirrors the contraction, starting with the contraction and returning to baseline as the contraction ends. The nadir of the

deceleration occurs at the peak of the contraction, which fits the pattern described.

Choice D rationale

Variable decelerations are abrupt decreases in FHR that can occur at any time during the contraction cycle, usually due to umbilical cord compression. They are not uniform in

relation to contractions and can vary in duration, depth, and timing, unlike the described pattern.

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