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?
Administer prescribed antipyretics for maternal fever.
Prepare the client for emergency cesarean section.
Administer glucocorticoids intramuscularly.
Recheck the client's temperature in 4 hr.
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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Correct Answer is B
Explanation
Choice A rationale
The fetal heartbeat cannot typically be heard via Doppler as early as 4 weeks of pregnancy. At this stage, the heart is still developing, and it is too soon for external detection with a Doppler device.
Choice B rationale
The fetal heartbeat is generally detectable by an external Doppler device around 10-12 weeks of pregnancy. This is the period when the heartbeat is strong enough to be picked up by the device.
Choice C rationale
Feeling the baby move, known as "quickening," typically occurs around 18-24 weeks of pregnancy, not 6 weeks. This sensation is different from hearing the heartbeat.
Choice D rationale
While the heart begins to form around week 5, it is not detectable by Doppler at 6 weeks. The technology does not have the sensitivity to detect such an early heartbeat externally.
Correct Answer is B
Explanation
Choice A rationale
Copious vernix is typically found on preterm newborns, not those born post-term.
Choice B rationale
Dry, cracked skin is a common finding in post-term newborns due to prolonged exposure to amniotic fluid.
Choice C rationale
Decreased subcutaneous fat is more likely in preterm newborns, while post-term newborns might lose some fat due to nutrient depletion.
Choice D rationale
Scant scalp hair is more common in preterm infants, whereas post-term infants usually have more developed hair. .