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
Accidental lacerations are possible during a cesarean delivery, but they are typically managed quickly and are not the most critical issue immediately after birth.
Choice B rationale
Respiratory distress is the priority assessment for a newborn following a cesarean delivery because cesarean births can increase the risk of transient tachypnea or other respiratory complications due to the lack of labor-induced respiratory adaptation.
Choice C rationale
Hypothermia is a concern for all newborns, but respiratory distress takes precedence in the immediate post-delivery period, especially following cesarean delivery.
Choice D rationale
Acrocyanosis is a common and typically benign condition in newborns, not requiring immediate intervention compared to respiratory distress.
Correct Answer is ["A","B","C","D","G"]
Explanation
Choice A: Respiratory assessment
The newborn is exhibiting signs of respiratory distress, such as mild grunting, nasal flaring, and intermittent retractions. These symptoms indicate potential respiratory issues that need immediate attention.
Choice B: Hemoglobin
The newborn's hemoglobin level is 9 g/dL, which is below the normal range of 14 to 24 g/dL2. This indicates anemia, which can affect the baby's oxygen-carrying capacity and overall health.
Choice C: Serum glucose
The newborn's serum glucose level is 38 mg/dL, which is below the normal range of 40 to 45 mg/dL2. Hypoglycemia in newborns can lead to serious complications if not addressed promptly.
Choice D: Heart rate
The newborn's heart rate is 180 beats per minute, which is above the normal range for a newborn (normal range: 120-160 beats per minute)2. This tachycardia could be a response to stress or an underlying condition that needs evaluation.
Choice G: Hematocrit
The newborn's hematocrit level is 35%, which is below the normal range of 44% to 64%2. This further supports the presence of anemia and the need for intervention2