A nurse is caring for a client who is at 16 weeks of gestation and reports a sudden gush of vaginal fluid.
Which of the following findings indicates premature rupture of membranes?

Choice A rationale: Weight is a crucial anthropometric measurement for evaluating a newborn's physical development, nutritional status, and overall health. It is typically recorded in grams or kilograms immediately after birth and monitored regularly. Normal birth weight is generally between 2,500 grams (5 lbs 8 oz) and 4,000 grams (8 lbs 13 oz). Deviations from this range, such as low birth weight, necessitate closer monitoring and specialized care.

Choice B rationale: The type of birth, whether vaginal, operative vaginal (e.g., forceps or vacuum assisted), or cesarean section, is a vital piece of obstetric history. This information is critical as it highlights potential risks the neonate may have encountered, such as transient tachypnea of the newborn following a C-section or trauma associated with a complicated vaginal delivery, and informs future care decisions.

Choice C rationale: The Apgar scores are a rapid, standardized assessment of five physiologic signs (Appearance, Pulse, Grimace, Activity, Respiration) used to evaluate a newborn's transition to extrauterine life. Scores are recorded at one and five minutes after birth. A score between 7 and 10 is considered normal and reassuring, while lower scores indicate the need for immediate intervention and closer observation.

Choice D rationale: Gestational age, typically determined by the last menstrual period and validated by a physical assessment (e.g., Ballard Scale), is essential for classifying the neonate as preterm, full-term, or post-term. It directly correlates with the maturity of organ systems, including the lungs and brain, and dictates the expected range of normal findings and potential risk for specific complications like hyperbilirubinemia or respiratory distress syndrome.

Choice E rationale: The heart rate is a fundamental vital sign, reflecting cardiovascular stability and is a key component of the Apgar score. Normal range for a newborn is typically 110 to 160 beats per minute. A sustained heart rate outside this range, either bradycardia or tachycardia, can signal distress, hypoxia, infection, or other underlying pathology, requiring immediate clinical investigation and intervention.

Choice F rationale: Length (or Crown-Heel length) is an important anthropometric measure recorded alongside weight and head circumference. It helps assess the newborn's growth potential and identify potential intrauterine growth restriction or genetic syndromes when plotted on standardized growth charts. Normal full-term length is generally between 45 and 55 centimeters (17.7 to 21.7 inches).

Choice A rationale

Applying warm, moist packs is generally used to promote circulation and relieve discomfort associated with an already-formed thrombus or thrombophlebitis, not as a primary prophylactic measure. Prevention centers on enhancing venous return and inhibiting clot formation, whereas heat application may slightly increase local vasodilation and is not the most effective primary preventative method in the immediate postpartum period.

Choice B rationale

Elastic stockings (anti-embolism stockings) apply external graduated compression to the legs. This compression aids in increasing the velocity of venous blood flow and reducing venous stasis, particularly in the lower extremities, thereby reducing the risk of Deep Vein Thrombosis (DVT) and subsequent thrombophlebitis, especially important when the client is at rest or in bed.

Choice C rationale

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are used primarily for pain management and reducing inflammation. While some NSAIDs possess mild antiplatelet effects, this is not their primary indication, nor is it a sufficiently robust measure to be considered a key intervention for preventing thrombophlebitis in the postpartum period, which necessitates focused mechanical or pharmacological prophylaxis.

Choice D rationale

Ambulation is crucial as it promotes muscle contraction of the lower extremities (the skeletal muscle pump), which mechanically compresses the deep veins and forces blood back toward the heart. This action significantly increases venous return, prevents venous stasis, and activates endogenous fibrinolysis, making early and frequent ambulation a cornerstone of thrombophlebitis prevention.