A nurse is caring for a 32-year-old female client who is at 36 weeks of gestation in the labor and delivery unit.
The nurse should monitor the client’s
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The condition that poses the greatest risk to the newborn is meconium aspiration syndrome due to amniotic fluid.
Rationale for correct answers
Meconium aspiration syndrome (MAS) occurs when a newborn inhales meconium-stained amniotic fluid, leading to airway obstruction, chemical pneumonitis, and surfactant dysfunction. The presence of dark brown-greenish amniotic fluid, along with mild respiratory distress (nasal flaring, increased respiratory rate of 60/min), raises concern for MAS. Close monitoring for worsening respiratory symptoms is essential.
Amniotic fluid contamination with meconium increases the risk of lung inflammation and infection. The newborn’s vigorous condition suggests mild aspiration, but continuous observation is needed.
Rationale for incorrect Response 1 options
- Jaundice: While term newborns may develop physiological jaundice, there are no indications of hyperbilirubinemia or hemolysis in this case.
- Hypoglycemia: No jitteriness or poor feeding, and birth weight is within normal range; hypoglycemia more commonly affects preterm or low birth weight infants.
- Cold stress: The newborn is under a radiant warmer, and temperature is within normal range (36.5°C).
Rationale for incorrect Response 2 options
- Birth weight: No signs of growth restriction or macrosomia-associated complications.
- Acrocyanosis: Normal in newborns due to immature circulation, not an indicator of respiratory compromise.
- Apgar scores: Strong Apgar scores (8 and 9) suggest good adaptation to extrauterine life.
Correct Answer is C
Explanation
Choice A rationale
Encouraging a hands-and-knees position can help rotate a fetus in an occiput posterior position or relieve back pain during labor. However, in hypotonic uterine dysfunction where contractions are weak and ineffective, this positional change alone is unlikely to augment labor significantly.
Choice B rationale
Providing a comfortable environment with dim lighting can reduce anxiety and promote relaxation, which might indirectly support labor progress. However, it does not directly address the issue of weak and ineffective uterine contractions characteristic of hypotonic dysfunction.
Choice C rationale
Administering oxytocin is the typical intervention for hypotonic uterine dysfunction after ruling out fetopelvic disproportion. Oxytocin is a synthetic hormone that stimulates uterine contractions, increasing their frequency, duration, and intensity to facilitate labor progress. It acts on the oxytocin receptors in the uterus, leading to smooth muscle contraction.
Choice D rationale
Preparing for an amniotomy (artificial rupture of membranes) might be considered to augment labor if the membranes are intact. However, since the woman's membranes have already ruptured, this intervention is not applicable in this situation. Amniotomy can sometimes stimulate or augment labor by releasing prostaglandins.
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