A nurse is reinforcing teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include?
Wipe from the back to front when performing perineal hygiene
Keep a daily record of fetal kick counts.
Avoid bubble bath solution when taking a tub bath.
Use a condom with sexual intercourse.
The Correct Answer is B
A. Wipe from the back to front when performing perineal hygiene: The correct method for perineal hygiene is to wipe front to back to reduce the risk of introducing bacteria into the vaginal area, especially in a client with PROM who is at risk for infection.
B. Keep a daily record of fetal kick counts: Monitoring fetal kick counts helps assess fetal well-being, particularly in a high-risk pregnancy like PROM at 26 weeks. It helps detect potential fetal distress early.
C. Avoid bubble bath solution when taking a tub bath: While avoiding bubble bath may help prevent irritation or infection, tub baths should be avoided entirely in cases of PROM to reduce the risk of ascending infection.
D. Use a condom with sexual intercourse. Sexual intercourse is contraindicated in clients with PROM due to the risk of infection.
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Related Questions
Correct Answer is B
Explanation
A. Take the client's temperature. Monitoring the client's temperature for signs of infection is important, but it is not the priority immediately following an amniotomy. Infection typically develops over time.
B. Check the fetal heart rate pattern. The priority after an amniotomy is to assess the fetal heart rate to detect any signs of umbilical cord prolapse or fetal distress, which can occur immediately after rupture of membranes.
C. Observe the color and consistency of amniotic fluid. Although it is important to observe amniotic fluid for abnormalities (e.g., meconium staining), the immediate priority is fetal heart rate monitoring.
D. Evaluate the client for signs of infection. Signs of infection should be monitored, but they are not the priority right after amniotomy.
Correct Answer is A
Explanation
A. Epidural Anesthesia. Epidural anesthesia involves injecting a local anesthetic into the epidural space, blocking pain signals from the lower body to the brain. It is commonly administered when the cervix is at least 4 cm dilated in active labor.
B. Local anesthesia. Local anesthesia numbs a specific, smaller area of the body and is typically used for procedures such as episiotomies or repairs, not for labor pain relief.
C. Pudendal block. A pudendal block is an injection that numbs the perineal area but does not block pain from contractions. It is used for pain relief during the second stage of labor or for episiotomies.
D. General anesthesia. General anesthesia affects the entire body and is rarely used in labor unless there is an emergency cesarean section when regional anesthesia is not possible.
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