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 C
Explanation
Choice A reason:
The purpose of a Jackson-Pratt (JP) drain is not to eliminate the need for wound irrigations. Wound irrigation is a critical step in wound care that helps remove debris, reduce bacterial load, and create an optimal environment for healing. The JP drain helps manage fluid accumulation but does not replace the need for proper wound irrigation.
Choice B reason:
While a JP drain can help manage bleeding by providing a pathway for blood to exit the wound, its primary purpose is not to limit bleeding. Instead, it is designed to prevent the accumulation of fluids such as blood, serous fluid, and other exudates that can impede healing and increase the risk of infection. Managing bleeding typically involves other interventions such as surgical hemostasis techniques.
Choice C reason:
The primary purpose of a Jackson-Pratt drain is to prevent fluid from accumulating in the wound. After surgery, wounds can produce various fluids, including blood and lymphatic fluid. Accumulation of these fluids can delay healing and increase the risk of infection. The JP drain uses gentle suction to draw these fluids away from the wound site, promoting faster healing and reducing the risk of complications.
Choice D reason:
A JP drain is not typically used to provide a means for medication administration. Medications are usually administered through other routes such as oral, intravenous, or through specialized catheters designed for medication delivery. The JP drain is specifically designed for fluid drainage and not for delivering medications.
Correct Answer is B
Explanation
Choice A reason:
Applying a heat lamp twice a day is not recommended for treating stage 3 pressure ulcers. Heat lamps can cause burns and further damage to the already compromised skin. The primary goal in treating pressure ulcers is to reduce pressure, keep the area clean, and promote healing. Heat lamps do not contribute to these goals and can potentially worsen the condition.
Choice B reason:
Repositioning the client at least every 2 hours is a crucial intervention for managing stage 3 pressure ulcers. Frequent repositioning helps to alleviate pressure on the affected area, improving blood flow and preventing further tissue damage. This practice is essential in preventing the progression of pressure ulcers and promoting healing. It is one of the most effective strategies in pressure ulcer management.
Choice C reason:
Massaging reddened areas with dressing changes is not advisable. Massaging can cause additional trauma to the skin and underlying tissues, potentially worsening the ulcer. Instead, gentle handling and appropriate wound care techniques should be used to avoid further damage. Massaging can also disrupt the healing process and increase the risk of infection.
Choice D reason:
Cleaning the wound with hydrogen peroxide solution is not recommended for stage 3 pressure ulcers. Hydrogen peroxide can damage healthy tissue and delay the healing process. It is better to use saline or other wound cleaning solutions that are gentle and effective in removing debris without harming the tissue. Proper wound cleaning is essential to prevent infection and promote healing.
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