A nurse is caring for a 34-year-old female client who is at 34 weeks of gestation in the antepartum unit.

Exhibits

What is the most appropriate action the nurse should take next?

Choice A rationale

Gestational age helps assess fetal development and potential complications. It is essential information for the provider to determine appropriate care and interventions.

Choice B rationale

Vaginal examination findings provide insight into cervical dilation, effacement, and station, which are critical for monitoring labor progress and making informed decisions about labor management.

Choice C rationale

Uterine contractions are a key indicator of labor progress. The frequency, duration, and intensity of contractions help the provider assess labor progression and plan necessary interventions.

Choice D rationale

Birthing parent's blood pressure is crucial for monitoring maternal well-being, especially in cases of pre-eclampsia or other hypertensive disorders. Elevated blood pressure can indicate complications that require immediate attention.

Choice E rationale

Birthing parent's report of pain, while important for comfort measures, is subjective and less critical for immediate clinical decision-making compared to the other findings.

Choice F rationale

Fetal heart rate monitoring provides essential information about the baby's well-being during labor. Abnormal heart rate patterns can indicate fetal distress and necessitate prompt intervention.

Complete the Sentence The priority intervention for the client with preterm premature rupture of membranes is to administer corticosteroids and administer prophylactic antibiotics.

Rationale for correct responses:

1. Administer corticosteroids: This is necessary to promote fetal lung maturity, which is crucial given the gestational age of 34 weeks.
2. Administer prophylactic antibiotics: This helps prevent maternal and fetal infection due to the rupture of membranes.

Rationale for incorrect responses:

1. Initiate tocolytic therapy: This is not the priority as the client is not currently experiencing contractions.
2. Prepare for immediate delivery: Immediate delivery is not indicated unless there are signs of fetal distress or maternal complications.
3. Perform digital cervical examination: This increases the risk of infection and is contraindicated in cases of ruptured membranes.
4. Administer Rh immunoglobulin: This is important but not the primary immediate intervention compared to corticosteroids and antibiotics.
5. Discharge the client for outpatient follow-up: This is inappropriate due to the need for close monitoring and prevention of infection.
6. Perform a biophysical profile: While useful, this is not a priority intervention compared to administering corticosteroids and antibiotics.