A primipara presents to the perinatal unit describing rupture of the membranes (ROM) occurring 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client’s contractions are irregular and mild. Based on this data, the nurse plans to monitor which sign more frequently than for the average laboring client?
Color of amniotic fluid.
Maternal temperature.
Deep tendon reflexes.
Maternal blood pressure.
The Correct Answer is B
Choice A rationale
Monitoring the color of amniotic fluid is crucial for assessing fetal well-being, but it is not the primary concern in the case of prolonged ROM. The focus should be on preventing maternal and fetal infection.
Choice B rationale
Maternal temperature should be monitored more frequently because prolonged ROM increases the risk of infection, particularly chorioamnionitis. Early detection of fever can prompt timely intervention to prevent complications.
Choice C rationale
Deep tendon reflexes are not directly affected by prolonged ROM. Monitoring them is more relevant for conditions like preeclampsia, where neurological assessment is critical. It is not the main concern in this scenario.
Choice D rationale
Maternal blood pressure is important to monitor but is not the primary focus in the context of prolonged ROM. The main concern is the increased risk of infection, necessitating closer monitoring of maternal temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While emergency cesarean birth preparation may be necessary in some cases, the primary focus should be on monitoring labor progression and the effects of oxytocin.
Choice B rationale
Monitoring the intensity, interval, and length of contractions is crucial in assessing the efficacy of oxytocin and ensuring the progress of labor while minimizing the risk of uterine hyperstimulation.
Choice C rationale
Checking the perineum for bulging is important in advanced labor stages but is not the primary focus when managing hypotonic dystocia and oxytocin administration.
Choice D rationale
Monitoring the client’s hourly blood pressure is important for overall health but is secondary to evaluating the contraction patterns and effectiveness of oxytocin in labor progression
Correct Answer is B
Explanation
Choice A rationale
Documenting the finding in the medical record is routine, but it does not address the potential concern of the fundal height discrepancy, which may indicate a need for further evaluation.
Choice B rationale
Scheduling a biophysical profile is crucial to assess the well-being of the fetuses, especially given the discrepancy in fundal height, which could indicate issues such as growth restriction or polyhydramnios.
Choice C rationale
Requesting another nurse to measure the fundus might help verify the measurement but does not address the potential underlying issue, which requires further assessment like a biophysical profile.
Choice D rationale
Notifying the healthcare provider is necessary, but it is more appropriate to first schedule a biophysical profile to gather comprehensive information on the fetal well-being before consulting the provider.
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