A primipara presents to the perinatal unit describing rupture of the membranes (ROM) occurring 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client’s contractions are irregular and mild. Based on this data, the nurse plans to monitor which sign more frequently than for the average laboring client?
Color of amniotic fluid.
Maternal temperature.
Deep tendon reflexes.
Maternal blood pressure.
The Correct Answer is B
Choice A rationale
Monitoring the color of amniotic fluid is crucial for assessing fetal well-being, but it is not the primary concern in the case of prolonged ROM. The focus should be on preventing maternal and fetal infection.
Choice B rationale
Maternal temperature should be monitored more frequently because prolonged ROM increases the risk of infection, particularly chorioamnionitis. Early detection of fever can prompt timely intervention to prevent complications.
Choice C rationale
Deep tendon reflexes are not directly affected by prolonged ROM. Monitoring them is more relevant for conditions like preeclampsia, where neurological assessment is critical. It is not the main concern in this scenario.
Choice D rationale
Maternal blood pressure is important to monitor but is not the primary focus in the context of prolonged ROM. The main concern is the increased risk of infection, necessitating closer monitoring of maternal temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Shallow and irregular respirations are normal for newborns and do not typically indicate respiratory distress. Regular assessment is necessary to determine if there is an underlying issue.
Choice B rationale
Flaring of the nares is a sign of increased effort to breathe and is an indication of respiratory distress in newborns. This symptom requires immediate attention to address potential underlying conditions.
Choice C rationale
Abdominal breathing with synchronous chest movement is normal in newborns due to their diaphragmatic breathing pattern. It does not indicate respiratory distress unless other symptoms are present.
Choice D rationale
A respiratory rate of 50 breaths per minute is within the normal range for newborns (30-60 breaths per minute). This does not indicate respiratory distress unless accompanied by other abnormal signs.
Correct Answer is D
Explanation
Choice A rationale
Asking another nurse to validate the costal angle finding is unnecessary, as the increased costal angle is a common physiological change during pregnancy due to the expanding uterus.
Choice B rationale
Examining for tissue anoxia, such as pallor, is not relevant in this scenario, as the nasal stuffiness and nosebleeds are likely due to increased blood volume and hormonal changes in pregnancy.
Choice C rationale
Requesting the healthcare provider to evaluate the client's respiratory status is unwarranted, as the described symptoms are typical physiological adaptations during pregnancy and not indicative of respiratory pathology.
Choice D rationale
Documenting the respiratory finding as normal is appropriate, as the increased chest circumference, thoracic breathing, elevated diaphragm, and increased costal angle are expected physiological changes during pregnancy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.