A nurse is assisting with the care of a client who is at 36 weeks of gestation and experienced preterm prelabor rupture of membranes. Which of the following actions should the nurse take?

Choice A reason:

The nurse's priority in this situation is the respiratory rate of 10/min. A respiratory rate of 10 breaths per minute is significantly low and could indicate respiratory depression, especially if the patient is receiving morphine, which is known to depress the respiratory system. This could lead to inadequate oxygenation, potential hypoxia, and other life-threatening complications.

Choice B reason:

Bladder distention may be a concern, but it is not the nurse's priority in this situation. Bladder distention can cause discomfort and urinary retention, but it is not an immediate life- threatening condition compared to potential respiratory depression.

Choice C reason:

A blood pressure of 108/64 mm Hg is within the normal range for an adolescent and may not be the nurse's priority at this time. Although it should be monitored, it does not pose an immediate threat to the patient's life.

Choice D reason:

Nausea and vomiting are common side effects of morphine administration, but they are not the nurse's priority in this situation. While they can cause distress and discomfort to the patient, they are not life-threatening conditions.

Choice A reason:

The nurse should not initiate contact precautions for a child with suspected epiglottitis. Epiglottitis is primarily caused by Haemophilus influenzae type B, and it spreads through respiratory droplets. Contact precautions are not necessary as the transmission occurs through droplets, and standard precautions should be sufficient.

Choice B reason:

The nurse should monitor pulse oximetry. Epiglottitis is a condition where the epiglottis becomes inflamed and swollen, potentially blocking the airway. Monitoring the child's pulse oximetry helps assess their oxygen saturation levels, which is crucial in determining if there is adequate oxygenation. If the oxygen saturation drops significantly, immediate intervention might be needed to maintain the child's airway and prevent hypoxia.

Choice C reason:

Obtaining a throat culture is not an appropriate intervention for suspected epiglottitis. In cases of suspected epiglottitis, the priority is to ensure the child's airway is maintained and that they receive appropriate medical attention promptly. Throat culture collection involves swabbing the throat to identify the infectious agent and is not a priority in this urgent situation.

Choice D reason:

Administering epinephrine IM is not indicated for suspected epiglottitis. Epinephrine is typically used to treat severe allergic reactions (anaphylaxis) and not for managing epiglottitis. The primary focus in epiglottitis is securing the airway and providing appropriate medical treatment, which might include antibiotics and respiratory support.