A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck.
When asked what happened, she states, "I walked into a door.”. What are the most appropriate interventions by the nurse?

Choice A rationale

Frequent cervical assessments increase the risk of introducing pathogens into the reproductive tract, especially with premature rupture of membranes (PROM). Continuous assessments are unnecessary unless labor is progressing or there are indications of infection. PROM exposes the fetus to potential infections like chorioamnionitis, and invasive procedures should be minimized to reduce infection risk.

Choice B rationale

Preparing for delivery is not a priority intervention unless signs of labor or fetal distress occur. At 32 weeks, preterm delivery poses significant risks, including respiratory distress syndrome and intraventricular hemorrhage. The goal is to prolong pregnancy to improve neonatal outcomes while closely monitoring the client for complications. Immediate delivery is reserved for emergent situations.

Choice C rationale

Providing emotional support is essential but does not directly address the risk of infection associated with PROM. While psychological support is beneficial, it is secondary to interventions aimed at preventing infection, which is the primary concern. Emotional well-being should complement, not replace, medical interventions.

Choice D rationale

Administering parenteral antibiotics helps prevent infection in cases of PROM, particularly when membranes rupture prematurely and expose the fetus to pathogens. Early antibiotic treatment reduces the risk of ascending infections like chorioamnionitis and neonatal sepsis. This intervention is crucial to protect maternal and fetal health during prolonged PROM.

Choice A rationale

Plantar creases appear over the entire sole closer to term gestation (37-40 weeks). At 30 weeks, these creases are confined to the anterior sole, reflecting the immature integumentary system. Absence of full creases correlates with preterm gestational age, assisting in clinical age assessment of neonates.

Choice B rationale

Preterm neonates at 30 weeks exhibit hypotonia, with minimal extremity flexion. Flexion develops progressively as the central nervous system matures. Hypotonia reflects developmental immaturity and is a distinguishing feature in preterm infants compared to term neonates.

Choice C rationale

Subcutaneous fat deposition is limited in preterm neonates, contributing to their thin, translucent skin and increased risk of thermoregulation issues. Fat accumulation occurs primarily in the third trimester, and its absence is a hallmark of premature neonates, requiring external temperature support.

Choice D rationale

Lanugo, a fine hair covering the body, is prominent in neonates born at 30 weeks. It serves as an adaptive mechanism for thermoregulation in utero. Lanugo decreases closer to term as subcutaneous fat increases. Its presence confirms preterm status and aids in gestational age assessment.