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 C
Explanation
Choice A rationale
G4T1 P1 A1 L2 implies the client has been pregnant 4 times, with 1 term birth, 1 preterm birth, 1 abortion, and 2 living children. This does not include the correct number of
pregnancies or abortions for this client.
Choice B rationale
G5T2 P0 A2 L2 indicates 5 pregnancies, 2 term births, no preterm births, 2 abortions, and 2 living children. This does not correctly account for the preterm birth and abortion history
provided.
Choice C rationale
G5T1 P1 A2 L2 is the correct answer, as it denotes 5 pregnancies (including the current one), 1 term birth, 1 preterm birth, 2 abortions, and 2 living children, aligning with the client's
history.
Choice D rationale
G5T1 P1 A1 L3 indicates 5 pregnancies, 1 term birth, 1 preterm birth, 1 abortion, and 3 living children. The client has only 2 living children, so this is incorrect.
Correct Answer is C
Explanation
Choice A rationale
A reaction from an epidural can cause side effects such as hypotension and shivering, but it is not related to tachysystole.
Choice B rationale
When the fetus's heart rate drops below baseline, it is termed bradycardia, not tachysystole. This condition can occur due to various reasons, including cord prolapse or placental insufficiency.
Choice C rationale
Tachysystole is defined as more than five contractions in 10 minutes. This condition can lead to reduced blood flow to the fetus, resulting in fetal distress.
Choice D rationale
Pitocin is a medication used to induce labor and can cause tachysystole, but the administration of Pitocin itself is not the definition of tachysystole. It's the increased frequency of contractions that defines the condition.