A client 40 weeks in early labor tells the nurse she feels wet.

The nurse observes spontaneous rupture of membranes with clear fluid.

Which nursing action is priority?

Choice A rationale

Erythromycin ophthalmic ointment is not primarily administered to prevent exudate from blocking tear ducts or causing dry eyes; rather, its prophylactic action targets specific bacterial pathogens. The medication's main purpose is to prevent neonatal ophthalmia, which is a serious infection of the conjunctiva that could otherwise cause severe visual impairment or blindness if left untreated after birth.

Choice B rationale

While erythromycin is an effective broad-spectrum antibiotic, the most critical pathogen it is administered to prevent is Neisseria gonorrhoeae, which causes severe ophthalmia neonatorum, not typically Staphylococcus. Although Staphylococcus can cause eye infections, the mandated prophylactic use targets N. gonorrhoeae and to some extent Chlamydia trachomatis to prevent blindness.

Choice C rationale

The ointment is not used to prevent the eyelids from sticking together or to immediately improve vision. The temporary blurring that often occurs after application may actually impair the infant's ability to see for a short period. The primary role is the destruction of specific pathogenic bacteria on the ocular surface that were potentially acquired during the passage through the birth canal.

Choice D rationale

This statement accurately describes the main rationale for administering prophylactic erythromycin ophthalmic ointment to all newborns. It specifically targets Neisseria gonorrhoeae, which can be transmitted during birth from an infected mother and cause severe ophthalmia neonatorum, leading to rapid corneal damage and permanent blindness if not prevented or promptly treated.

Choice A rationale

These vital signs, though slightly elevated in heart rate, are within generally acceptable limits for a post-vaginal birth patient 1 hour postpartum. A heart rate of 100 bpm may reflect minor stress or pain, and a blood pressure of 126/68 mm Hg is adequate. The temperature of 37.4°C is normal, and respirations at 18 are unremarkable. These values do not strongly suggest immediate, life-threatening instability following a significant blood loss.

Choice B rationale

A heart rate of 115 bpm and a blood pressure of 90/50 mm Hg indicate a concerning state of hypovolemic shock, especially when coupled with an estimated blood loss (EBL) of 1500 mL. Tachycardia (HR > 100 bpm) and hypotension (BP < 90/60 mm Hg) are classic compensatory mechanisms to maintain cardiac output following substantial hemorrhage, which is the greatest concern post-delivery.

Choice C rationale

A temperature of 38°C is the upper limit of normal for the first 24 hours postpartum and may be related to dehydration or exertion during labor. A heart rate of 80 bpm is within the normal range (60-100 bpm), and a blood pressure of 110/80 mm Hg is stable. These findings are less critical than signs of hypovolemia.

Choice D rationale

A heart rate of 60 bpm, known as puerperal bradycardia, is a common and usually benign finding during the first week postpartum due to circulatory readjustments. A blood pressure of 140/90 mm Hg is borderline elevated but is not immediately as alarming as the signs of shock presented in Choice B, particularly with the 1500 mL EBL.