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 ["A","B","C","F"]
Explanation
Choice A rationale:
A postpartum temperature of 100.4°F (38.0°C) or higher may indicate an infection. Infections can occur after delivery, particularly if there was a manual extraction of the placenta, as in
this case. Close monitoring and further assessment are necessary to ensure the client does not develop sepsis or other complications.
Choice B rationale:
Fundal tone should be firm and well-contracted to prevent excessive bleeding postpartum. A boggy, midline fundus suggests that the uterus is not contracting effectively, increasing the
risk for postpartum hemorrhage. This requires immediate attention and intervention to ensure adequate uterine tone and control bleeding.
Choice C rationale:
Lochia should be monitored for quantity, color, and the presence of clots. Heavy lochia with small clots indicates that the client may be experiencing postpartum hemorrhage, which is a
significant concern. This can be related to uterine atony, retained placental fragments, or coagulopathies and warrants prompt evaluation and intervention.
Choice D rationale:
A respiratory rate of 17/min is within the normal adult range (12-20/min) and does not require follow-up. There are no signs of respiratory distress or abnormalities in this case, indicating
that the client's respiratory status is stable and does not necessitate further evaluation.
Choice E rationale:
A white blood cell count of 12,000/mm³ is within the expected range for postpartum women, where normal values can be elevated due to physiological stress and inflammation from
delivery. This level does not indicate infection or pathology and does not require follow-up in the context provided.
Choice F rationale:
Blood pressure of 144/92 mmHg is elevated and concerning, particularly in a postpartum client with a history of chronic hypertension and gestational diabetes. This could signal
postpartum preeclampsia or other hypertensive disorders, requiring careful monitoring and management to prevent complications like seizures, stroke, or organ damage.
Correct Answer is A
Explanation
Choice A rationale
Blood pressure should be addressed first due to the client’s elevated BP (144/92 mmHg), which is a potential sign of complications such as preeclampsia.
Choice B rationale
Pulse of 99 bpm is slightly elevated but not immediately concerning compared to the high BP.
Choice C rationale
Respirations are within normal range (17/min) and do not require immediate intervention.
Choice D rationale
Temperature of 100.4°F (38.0°C) is slightly elevated but not as critical as the high BP.