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A nurse is caring for a 32-year-old female client who is at 36 weeks of gestation in the labor and delivery unit.

Exhibits

The nurse should monitor the client’s

due to the risk of .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

The nurse should monitor the client’s temperature due to the risk of chorioamnionitis.

Rationale for correct answers

Temperature monitoring is crucial for detecting chorioamnionitis, an infection of the amniotic sac, which is a major risk following preterm premature rupture of membranes (PPROM). PPROM increases susceptibility to ascending bacterial infection, leading to inflammation. Fever (>38°C or 100.4°F) is a primary diagnostic criterion.

Chorioamnionitis presents with maternal fever, fetal tachycardia (>160/min), uterine tenderness, and foul-smelling amniotic fluid. The client's normal temperature now (36.7°C) requires ongoing monitoring, as infection could develop rapidly.

Rationale for incorrect Response 1 options

  • Magnesium levels: Magnesium sulfate is used for seizure prophylaxis in eclampsia or for neuroprotection in preterm labor. This client has no signs of either condition.
  • Fundal height: Measurement assesses fetal growth and amniotic fluid levels; it is not a direct indicator of infection risk.
  • Clotting factors: No evidence of coagulopathy or bleeding abnormalities; coagulation profile is normal.

Rationale for incorrect Response 2 options

  • Concealed hemorrhage: No signs of placental abruption (painful bleeding, rigid abdomen). Normal hemoglobin (12.0 g/dL) supports this.
  • Seizures: No hypertensive crisis or neurological symptoms suggestive of eclampsia.
  • Disseminated intravascular coagulation (DIC): No abnormal coagulation markers or evidence of excessive bleeding.

Take-home points

• PPROM increases the risk of chorioamnionitis, a serious intrauterine infection. • Fever monitoring is essential, as maternal fever is an early indicator of infection. • Antibiotics are given prophylactically to reduce chorioamnionitis risk in PPROM. • Differentiation from placental abruption, eclampsia, and DIC is based on clinical and laboratory findings.


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Related Questions

Correct Answer is ["7"]

Explanation

Step 1: Heart rate of 110/min scores 2 points (normal heart rate >100).

Step 2: Slow weak cry scores 1 point (good strong cry scores 2, no cry scores 0).

Step 3: Some flexion of extremities scores 1 point (active movement scores 2, limp scores 0).

Step 4: Grimace in response to suctioning scores 1 point (coughing or sneezing scores 2, no response scores 0).

Step 5: Body pink, blue extremities scores 1 point (completely pink scores 2, completely blue or pale scores 0).

Step 6: Total Apgar score is the sum of the scores from each category: 2 + 1 + 1 + 1 + 2 = 7. Final calculated answer: 7.

Correct Answer is C

Explanation

Choice A rationale

Encouraging a hands-and-knees position may help rotate a malpositioned fetus or relieve back pain, but it does not directly address hypotonic uterine dysfunction, which is characterized by weak, ineffective contractions. While it can improve maternal comfort and potentially aid in fetal descent if malpositioning is a contributing factor to slow labor progress, it will not augment the strength or frequency of contractions necessary for cervical dilation.

Choice B rationale

Providing a comfortable environment with dim lighting can promote relaxation and potentially enhance the progress of labor in cases of hypertonic uterine dysfunction (uncoordinated, painful contractions). However, in hypotonic dysfunction, the issue is a lack of adequate uterine muscle activity. While comfort measures are always important, they do not directly stimulate stronger contractions.

Choice C rationale

Administering oxytocin is the primary medical intervention for hypotonic uterine dysfunction. Oxytocin is a synthetic hormone that stimulates uterine smooth muscle to contract more frequently and with greater intensity. This augmentation of uterine activity aims to establish an effective labor pattern, leading to cervical dilation and fetal descent when fetopelvic disproportion has been ruled out.

Choice D rationale

Preparing for an amniotomy (artificial rupture of membranes) might be considered to augment labor if the membranes are intact. However, the question states the membranes have already ruptured. Amniotomy can sometimes stimulate contractions by releasing prostaglandins, but it is not the first-line intervention for established hypotonic dysfunction after membrane rupture, and oxytocin is generally more effective in this situation.

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