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:
The statement “Please do not raise your voice at the children. I am the one who left the dishes in the sink.” is an example of effective communication. It demonstrates taking responsibility for one’s actions and addressing the issue calmly and directly. This approach helps to de-escalate potential conflict and promotes a respectful and constructive dialogue among family members. Effective communication in family therapy involves clear, honest, and respectful exchanges that foster understanding and resolution of issues.
Choice B reason:
The statement “If you keep saying that, I will tell everyone what you did last night.” is an example of ineffective communication. It is threatening and manipulative, which can escalate conflict and create a hostile environment. Such statements undermine trust and respect among family members, making it difficult to resolve issues constructively. Effective communication should avoid threats and focus on expressing feelings and concerns in a non-confrontational manner.
Choice C reason:
The statement “Can you tell me the reason you get upset each time I go to the mall?” is a step towards effective communication as it seeks to understand the other person’s feelings. However, it could be improved by using “I” statements to express personal feelings and concerns. For example, “I feel concerned when you get upset each time I go to the mall. Can we talk about it?” This approach reduces defensiveness and encourages open dialogue.
Choice D reason:
The statement “She is always bossing me around. Should she do that?” is an example of ineffective communication. It is accusatory and does not address the issue constructively. Effective communication should focus on specific behaviors and how they affect the individual, rather than making general accusations. For example, “I feel frustrated when I am told what to do. Can we discuss how we can share responsibilities more fairly?” This approach promotes understanding and cooperation.
Correct Answer is A
Explanation
Choice A reason: Withhold oral fluids and food
Withholding oral fluids and food (NPO status) is a critical intervention for clients with acute pancreatitis. This helps to rest the pancreas by reducing the stimulation of pancreatic enzyme secretion, which can exacerbate inflammation and pain. Maintaining NPO status is essential to prevent further pancreatic damage and to allow the pancreas to heal.
Choice B reason: Auscultate the client’s lungs
While auscultating the lungs is an important part of the overall assessment, it is not the immediate priority after pain management in acute pancreatitis. Respiratory complications can occur, but the primary focus should be on managing the pancreatic inflammation and preventing further damage.
Choice C reason: Provide oral hygiene
Providing oral hygiene is important for overall patient care, especially when the client is NPO. However, it is not the priority intervention immediately after pain management. The primary concern is to prevent further pancreatic stimulation and manage the inflammation.
Choice D reason: Assist the client to a side-lying position
Assisting the client to a side-lying position can help with comfort and may be beneficial in managing pain. However, it is not the priority intervention. The main focus should be on preventing further pancreatic stimulation by withholding oral intake.
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