A nurse is caring for a client who is pregnant and was admitted 6 days ago for preterm prelabor rupture of membranes (PPROM).
A nurse is performing a follow-up assessment on the client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Potential Condition: Chorioamnionitis
Chorioamnionitis is an infection of the amniotic fluid, membranes, placenta, and/or decidua. It is often associated with preterm prelabor rupture of membranes (PPROM), especially when there is a prolonged rupture of membranes, as in this case. The client’s symptoms, including a high temperature (38.2°C), elevated heart rate (112/min), and purulent amniotic fluid, strongly suggest an intra-amniotic infection.
Potential Condition: Abruptio Placentae
Abruptio placentae, also known as placental abruption, is the premature separation of the placenta from the uterine wall before childbirth. This condition can lead to significant maternal hemorrhage and jeopardize the well-
being of the fetus. The primary symptoms include vaginal bleeding, abdominal pain, uterine tenderness, and contractions. In severe cases, it can cause maternal shock and fetal distress or death. The client’s symptoms, such as abdominal discomfort and contractions, could be indicative of this condition, but the presence of purulent amniotic fluid and fever makes chorioamnionitis a more likely diagnosis in this scenario.
Potential Condition: Prolapsed Umbilical Cord
A prolapsed umbilical cord occurs when the umbilical cord slips ahead of the fetal presenting part and prolapses into the cervical canal, vagina, or beyond. This is an obstetric emergency because the prolapsed cord can be compressed, cutting off the baby’s blood and oxygen supply. The primary signs include visible or palpable cord at the cervix or in the vagina, and sudden changes in fetal heart rate patterns, such as bradycardia or variable
decelerations. While the client’s fetal heart rate is elevated, there is no indication of a visible or palpable cord, making this condition less likely.
Potential Condition: Preeclampsia
Preeclampsia is a pregnancy-specific condition characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. It can lead to serious complications such as eclampsia, HELLP syndrome, and organ damage. Symptoms include high blood pressure, proteinuria, severe headaches, visual disturbances, and epigastric pain. The client’s history of chronic hypertension and elevated heart rate could suggest preeclampsia, but the absence of high blood pressure and proteinuria in the current assessment makes this diagnosis less likely compared to chorioamnionitis.
Choice A: Prepare to administer gentamicin IV
Gentamicin is an aminoglycoside antibiotic that is often used in combination with other antibiotics to treat chorioamnionitis. It is effective against a broad range of bacteria that could be causing the infection. Administering gentamicin IV can help manage the infection and prevent further complications for both the mother and the fetus34.
Choice B: Obtain a prescription for hydraclone PO
Hydraclone is not a standard treatment for chorioamnionitis. The primary treatment involves antibiotics to manage the infection. Therefore, this option is not appropriate in this scenario.
Choice C: Place the client in the Trendelenburg position
The Trendelenburg position, where the patient is laid flat on their back with their feet higher than their
head, is not indicated for chorioamnionitis. This position is typically used in cases of umbilical cord prolapse to relieve pressure on the cord.
Choice D: Place the client in a quiet environment
While placing the client in a quiet environment may help with overall comfort, it does not directly address the infection or its complications. Therefore, it is not a primary action in managing chorioamnionitis.
Choice E: Educate the client on the process of inducing labor
Inducing labor may be necessary in cases of chorioamnionitis to reduce the risk of complications for both the mother and the baby. Prompt delivery is often recommended once the infection is diagnosed to prevent further maternal and fetal morbidity.
Parameters to Monitor:
Choice A: Uric acid levels
Monitoring uric acid levels can help assess the client’s overall metabolic state and detect any potential complications such as preeclampsia, which can coexist with chorioamnionitis.
Choice B: Deep tendon reflexes
Deep tendon reflexes are typically monitored in cases of preeclampsia to assess for hyperreflexia, which is not relevant in the context of chorioamnionitis.
Choice C: Dysfunctional labor
Monitoring for dysfunctional labor is important but not specific to chorioamnionitis. The primary focus should be on managing the infection and monitoring maternal and fetal well-being.
Choice D: Maternal body temperature
Maternal body temperature is a critical parameter to monitor in cases of chorioamnionitis. An elevated temperature is a key indicator of infection, and monitoring it helps assess the effectiveness of the treatment.
Choice E: Inadequate uterine reduction
Inadequate uterine reduction is not a relevant parameter in the context of chorioamnionitis. The focus should be on monitoring signs of infection and maternal and fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A: Diminished Lung Sounds
Reason: Diminished lung sounds can indicate several serious conditions that require immediate follow-up. In the context of a patient who has just undergone a thoracentesis, diminished lung sounds could suggest a pneumothorax (collapsed lung), which is a known complication of the procedure. Pneumothorax occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse. This condition can lead to severe respiratory distress and requires prompt intervention, such as the insertion of a chest tube to re-expand the lung. Additionally, diminished lung sounds could indicate reaccumulation of pleural fluid, which would necessitate further drainage or other interventions.
Choice B: Heart Rate 110/min and Regular
Reason: A heart rate of 110 beats per minute (bpm) is considered tachycardia, which is above the normal resting heart rate range of 60-100 bpm for adults. In elderly patients, a heart rate above 100 bpm can be particularly concerning as it may indicate underlying issues such as hypoxemia (low blood oxygen levels), infection, or cardiac problems. Tachycardia following a thoracentesis could be a sign of respiratory distress or pain, both of which require immediate assessment and management. It is crucial to determine the underlying cause of the elevated heart rate to prevent further complications.
Choice C: Oxygen Saturation of 95%
Reason: An oxygen saturation level of 95% is generally considered within the normal range (95-100%) for healthy individuals. However, in the context of a patient with a history of lung cancer, pleural effusions, and recent thoracentesis, this value might be borderline. While it does not require immediate follow-up, it should be monitored closely. Any further drop in oxygen saturation would necessitate intervention, such as supplemental oxygen or further diagnostic testing to determine the cause of the hypoxemia.
Choice D: Subcutaneous Emphysema
Reason: Subcutaneous emphysema is the presence of air in the subcutaneous tissue, which can occur as a complication of thoracentesis. It is often identified by a characteristic crackling sensation felt under the skin. This condition can indicate a more serious underlying issue, such as a pneumothorax or tracheal injury, both of which require immediate medical attention. Management of subcutaneous emphysema involves addressing the underlying cause, which may include the insertion of a chest tube or other interventions to remove the trapped air and prevent further complications.
Choice E: Trachea Midline
Reason: The trachea being midline is a normal finding and does not require immediate follow-up. A deviation of the trachea to one side can indicate a tension pneumothorax or significant pleural effusion, both of which are medical emergencies. However, in this case, the trachea is midline, suggesting that there is no immediate concern related to tracheal deviation.
Choice F: Puncture Site Dry
Reason: A dry puncture site is a normal finding post-thoracentesis and does not require immediate follow-up. It indicates that there is no active bleeding or significant fluid leakage from the site. The dressing should be monitored for any signs of infection or excessive drainage, but a dry puncture site is generally a positive sign of proper healing.
Correct Answer is A
Explanation
Choice A reason:
The statement “Fetal position is persistent occiput posterior” is correct. The occiput posterior (OP) position is when the baby’s head is down but facing the mother’s abdomen. This position can cause prolonged labor and severe backache because the baby’s head is not optimally aligned with the birth canal, making it harder for the baby to descend. The OP position often leads to more painful and prolonged labor, and it is associated with a higher likelihood of interventions such as forceps or vacuum delivery, or even cesarean section.
Choice B reason:
The statement “Maternal pelvis is gynecoid” is incorrect as a contributing cause for difficult labor. A gynecoid pelvis is the most favorable pelvic shape for childbirth. It is round and wide, providing ample space for the baby to pass through the birth canal. Women with a gynecoid pelvis typically experience smoother and less complicated deliveries.
Choice C reason:
The statement “Fetal attitude is in general flexion” is also incorrect as a contributing cause for difficult labor. General flexion is the normal fetal attitude, where the baby’s chin is tucked to the chest, and the limbs are flexed. This position allows the smallest diameter of the baby’s head to present first, facilitating an easier passage through the birth canal.
Choice D reason:
The statement “Fetal lie is longitudinal” is incorrect as a contributing cause for difficult labor. A longitudinal lie means that the baby’s spine is aligned with the mother’s spine, which is the normal and most common orientation for delivery. This position is generally favorable for childbirth.
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