A nurse is caring for a client who is pregnant and was admitted 6 days ago for preterm prelabor rupture of membranes (PPROM).
A nurse is performing a follow-up assessment on the client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Potential Condition: Chorioamnionitis
Chorioamnionitis is an infection of the amniotic fluid, membranes, placenta, and/or decidua. It is often associated with preterm prelabor rupture of membranes (PPROM), especially when there is a prolonged rupture of membranes, as in this case. The client’s symptoms, including a high temperature (38.2°C), elevated heart rate (112/min), and purulent amniotic fluid, strongly suggest an intra-amniotic infection.
Potential Condition: Abruptio Placentae
Abruptio placentae, also known as placental abruption, is the premature separation of the placenta from the uterine wall before childbirth. This condition can lead to significant maternal hemorrhage and jeopardize the well-
being of the fetus. The primary symptoms include vaginal bleeding, abdominal pain, uterine tenderness, and contractions. In severe cases, it can cause maternal shock and fetal distress or death. The client’s symptoms, such as abdominal discomfort and contractions, could be indicative of this condition, but the presence of purulent amniotic fluid and fever makes chorioamnionitis a more likely diagnosis in this scenario.
Potential Condition: Prolapsed Umbilical Cord
A prolapsed umbilical cord occurs when the umbilical cord slips ahead of the fetal presenting part and prolapses into the cervical canal, vagina, or beyond. This is an obstetric emergency because the prolapsed cord can be compressed, cutting off the baby’s blood and oxygen supply. The primary signs include visible or palpable cord at the cervix or in the vagina, and sudden changes in fetal heart rate patterns, such as bradycardia or variable
decelerations. While the client’s fetal heart rate is elevated, there is no indication of a visible or palpable cord, making this condition less likely.
Potential Condition: Preeclampsia
Preeclampsia is a pregnancy-specific condition characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. It can lead to serious complications such as eclampsia, HELLP syndrome, and organ damage. Symptoms include high blood pressure, proteinuria, severe headaches, visual disturbances, and epigastric pain. The client’s history of chronic hypertension and elevated heart rate could suggest preeclampsia, but the absence of high blood pressure and proteinuria in the current assessment makes this diagnosis less likely compared to chorioamnionitis.
Choice A: Prepare to administer gentamicin IV
Gentamicin is an aminoglycoside antibiotic that is often used in combination with other antibiotics to treat chorioamnionitis. It is effective against a broad range of bacteria that could be causing the infection. Administering gentamicin IV can help manage the infection and prevent further complications for both the mother and the fetus34.
Choice B: Obtain a prescription for hydraclone PO
Hydraclone is not a standard treatment for chorioamnionitis. The primary treatment involves antibiotics to manage the infection. Therefore, this option is not appropriate in this scenario.
Choice C: Place the client in the Trendelenburg position
The Trendelenburg position, where the patient is laid flat on their back with their feet higher than their
head, is not indicated for chorioamnionitis. This position is typically used in cases of umbilical cord prolapse to relieve pressure on the cord.
Choice D: Place the client in a quiet environment
While placing the client in a quiet environment may help with overall comfort, it does not directly address the infection or its complications. Therefore, it is not a primary action in managing chorioamnionitis.
Choice E: Educate the client on the process of inducing labor
Inducing labor may be necessary in cases of chorioamnionitis to reduce the risk of complications for both the mother and the baby. Prompt delivery is often recommended once the infection is diagnosed to prevent further maternal and fetal morbidity.
Parameters to Monitor:
Choice A: Uric acid levels
Monitoring uric acid levels can help assess the client’s overall metabolic state and detect any potential complications such as preeclampsia, which can coexist with chorioamnionitis.
Choice B: Deep tendon reflexes
Deep tendon reflexes are typically monitored in cases of preeclampsia to assess for hyperreflexia, which is not relevant in the context of chorioamnionitis.
Choice C: Dysfunctional labor
Monitoring for dysfunctional labor is important but not specific to chorioamnionitis. The primary focus should be on managing the infection and monitoring maternal and fetal well-being.
Choice D: Maternal body temperature
Maternal body temperature is a critical parameter to monitor in cases of chorioamnionitis. An elevated temperature is a key indicator of infection, and monitoring it helps assess the effectiveness of the treatment.
Choice E: Inadequate uterine reduction
Inadequate uterine reduction is not a relevant parameter in the context of chorioamnionitis. The focus should be on monitoring signs of infection and maternal and fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Decreasing the infusion rate is the appropriate action when a client experiences flushing and tachycardia while receiving IV vancomycin. These symptoms are indicative of “Red Man Syndrome,” a reaction that occurs when vancomycin is infused too quickly. Slowing the infusion rate can help alleviate these symptoms and prevent further complications.
Choice B reason:
Changing the IV infusion site is not necessary in this situation. The symptoms of flushing and tachycardia are related to the rate of vancomycin infusion, not the site of administration. Therefore, changing the site would not address the underlying issue.
Choice C reason:
Documenting that the client experienced an anaphylactic reaction to the medication is incorrect. Anaphylaxis is a severe, life-threatening allergic reaction that involves symptoms such as difficulty breathing, swelling of the face and throat, and a rapid drop in blood pressure. The symptoms described (flushing and tachycardia) are more consistent with Red Man Syndrome, not anaphylaxis.
Choice D reason:
Applying cold compresses to the neck area is not an effective intervention for managing the symptoms of Red Man Syndrome. The primary approach should be to slow the infusion rate of vancomycin. Cold compresses would not address the cause of the reaction.
Correct Answer is A
Explanation
Choice A reason: A private room in a quiet location on the unit is the best option for a client in the manic phase of bipolar disorder. This environment minimizes stimulation and distractions, which can help reduce agitation and hyperactivity. It also allows for better control of the client’s environment, which is crucial for managing manic symptoms.
Choice B reason: A private room across from the exercise room is not ideal because the proximity to the exercise room can increase stimulation and noise, potentially exacerbating manic symptoms. Clients in the manic phase need a calm and quiet environment to help stabilize their mood.
Choice C reason: A semi-private room across from the day room is also not suitable. The day room is typically a busy area with a lot of activity and noise, which can be overstimulating for a client in the manic phase. Sharing a room with another client can further increase the risk of agitation and conflict.
Choice D reason: A semi-private room across from the snack area is not recommended for similar reasons. The snack area is likely to have frequent traffic and noise, which can be disruptive. Additionally, sharing a room can lead to increased stimulation and potential conflicts with a roommate.
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