An antenatal client at 32 weeks' gestation has been admitted to the hospital with premature rupture of membranes.
She is not exhibiting any signs of labor.
What is the priority nursing intervention for this client?
Assess cervical dilation every 2 hours.
Prepare for delivery.
Provide emotional support.
Administer parenteral antibiotics.
The Correct Answer is D
Choice A rationale
Frequent cervical assessments increase the risk of introducing pathogens into the reproductive tract, especially with premature rupture of membranes (PROM). Continuous assessments are unnecessary unless labor is progressing or there are indications of infection. PROM exposes the fetus to potential infections like chorioamnionitis, and invasive procedures should be minimized to reduce infection risk.
Choice B rationale
Preparing for delivery is not a priority intervention unless signs of labor or fetal distress occur. At 32 weeks, preterm delivery poses significant risks, including respiratory distress syndrome and intraventricular hemorrhage. The goal is to prolong pregnancy to improve neonatal outcomes while closely monitoring the client for complications. Immediate delivery is reserved for emergent situations.
Choice C rationale
Providing emotional support is essential but does not directly address the risk of infection associated with PROM. While psychological support is beneficial, it is secondary to interventions aimed at preventing infection, which is the primary concern. Emotional well-being should complement, not replace, medical interventions.
Choice D rationale
Administering parenteral antibiotics helps prevent infection in cases of PROM, particularly when membranes rupture prematurely and expose the fetus to pathogens. Early antibiotic treatment reduces the risk of ascending infections like chorioamnionitis and neonatal sepsis. This intervention is crucial to protect maternal and fetal health during prolonged PROM.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct Answer is A
Explanation
Choice A rationale
Blue-gray discolorations on the sacrum, commonly known as Mongolian spots, are benign skin markings that frequently appear in newborns of Asian, African, and Hispanic descent. Documenting this finding ensures accurate medical records and prevents misinterpretation of these congenital marks as bruising.
Choice B rationale
There is no need to notify the healthcare provider about Mongolian spots unless there is uncertainty regarding their origin. These spots are non-pathological and typically fade within the first years of life, requiring no medical intervention or immediate attention.
Choice C rationale
Clotting studies are unnecessary for blue-gray discoloration because Mongolian spots are not related to blood clotting disorders. They are caused by the accumulation of melanocytes in the dermis during fetal development, a harmless pigmentation phenomenon.
Choice D rationale
Reporting parents to Child Protective Services in this context would be inappropriate and unjustified. Mongolian spots are a common and well-documented congenital skin feature, not indicative of abuse, and misinterpreting them could lead to undue stress and harm to the family. .
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