A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Tocolytic therapy is used to delay preterm labor and prevent premature birth. 2. Administering tocolytic therapy at 26 weeks of gestation allows time for corticosteroids to enhance fetal lung maturity. 3. Delaying labor at this stage can improve neonatal outcomes. 4. Other choices are incorrect because tocolytic therapy is not indicated for fetal death, Braxton-Hicks contractions, or post-term pregnancy.

Correct Answer: B

Rationale: The correct answer is B: Nipple line. This landmark is used for measuring newborn chest circumference as it ensures consistency in measurement and is a reliable reference point. The nipple line is anatomically consistent and easily identifiable, making it the ideal landmark for accurate measurements. Rationale: A: Sternal notch is not recommended for chest circumference measurement in newborns as it is not a consistent landmark and may vary among individuals. C: Xiphoid process is not suitable for chest circumference measurement as it is located at the lower end of the sternum and not commonly used for this purpose. D: Fifth intercostal space is not a recommended landmark for chest circumference measurement in newborns as it is not as reliable and consistent as the nipple line.

Correct Answer: C

Rationale: The correct answer is C: Assess the odor of the amniotic fluid. This is the appropriate nursing action because the woman is at risk for chorioamnionitis due to the elevated temperature and ruptured membranes. Assessing the odor of the amniotic fluid can help in identifying signs of infection, as foul-smelling amniotic fluid may indicate chorioamnionitis. This can guide further interventions and management, such as initiating antibiotics. Choice A is incorrect as waiting 4 hours to recheck the temperature can delay necessary interventions for potential infection. Choice B is also incorrect as administering glucocorticoids is not the immediate priority in this situation. Choice D is incorrect as preparing for an emergency cesarean section is not warranted solely based on the client's temperature and ruptured membranes without further assessment for infection.

Correct Answer: A

Rationale: The correct answer is A. Rubella immunization should be given shortly after giving birth to prevent any potential harm to the fetus during pregnancy. Immunization during pregnancy is contraindicated to avoid any risk of harm to the developing baby. Option B is incorrect as immunization in the third trimester can still pose a risk to the fetus. Option C is incorrect as immediate immunization during pregnancy is not recommended. Option D is incorrect as waiting until the next attempt to get pregnant does not protect the current fetus.

Correct Answer: A

Rationale: The correct answer is A because the maternal serum alpha-fetoprotein test is specifically used to screen for neural tube defects and other developmental abnormalities in the fetus. Alpha-fetoprotein levels in the mother's blood can indicate the presence of such abnormalities. This test is typically done around 15-20 weeks of gestation. Choice B is incorrect because the maternal serum alpha-fetoprotein test is not used to assess various markers of fetal well-being. Choice C is incorrect because it does not identify Rh incompatibility, which is typically detected through other tests. Choice D is incorrect because the test is not primarily for spinal defects, but rather for neural tube defects and other developmental abnormalities.