An antenatal client at 32 weeks' gestation has been admitted to the hospital with premature rupture of membranes.
She is not exhibiting any signs of labor.
What is the priority nursing intervention for this client?
Assess cervical dilation every 2 hours.
Prepare for delivery.
Provide emotional support.
Administer parenteral antibiotics.
The Correct Answer is D
Choice A rationale
Frequent cervical assessments increase the risk of introducing pathogens into the reproductive tract, especially with premature rupture of membranes (PROM). Continuous assessments are unnecessary unless labor is progressing or there are indications of infection. PROM exposes the fetus to potential infections like chorioamnionitis, and invasive procedures should be minimized to reduce infection risk.
Choice B rationale
Preparing for delivery is not a priority intervention unless signs of labor or fetal distress occur. At 32 weeks, preterm delivery poses significant risks, including respiratory distress syndrome and intraventricular hemorrhage. The goal is to prolong pregnancy to improve neonatal outcomes while closely monitoring the client for complications. Immediate delivery is reserved for emergent situations.
Choice C rationale
Providing emotional support is essential but does not directly address the risk of infection associated with PROM. While psychological support is beneficial, it is secondary to interventions aimed at preventing infection, which is the primary concern. Emotional well-being should complement, not replace, medical interventions.
Choice D rationale
Administering parenteral antibiotics helps prevent infection in cases of PROM, particularly when membranes rupture prematurely and expose the fetus to pathogens. Early antibiotic treatment reduces the risk of ascending infections like chorioamnionitis and neonatal sepsis. This intervention is crucial to protect maternal and fetal health during prolonged PROM.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6"]
Explanation
The correct answer is Apgar score of 6.
Step 1 is to evaluate each of the five components of the Apgar score at 1 minute:
- Heart rate: 120/min scores 2 points (normal heart rate is ≥100 beats per minute).
- Respiratory effort: Slow and weak cry scores 1 point (normal is a strong cry, scoring 2 points).
- Muscle tone: Some flexion of extremities scores 1 point (normal is active motion, scoring 2 points).
- Reflex irritability: Grimace in response to suctioning scores 1 point (normal is crying or withdrawal, scoring 2 points).
- Color: Body pink with blue extremities scores 1 point (normal is completely pink, scoring 2 points).
Step 2 is to sum up the points. (2 + 1 + 1 + 1 + 1) = Apgar score of 6. .
Correct Answer is ["75"]
Explanation
Step 1 is (50 mg × 6 kg) ÷ 24 hours. The total daily dose calculates to 300 mg/day.
Step 2 is 300 mg ÷ 4 doses/day. Each dose calculates to 75 mg of Amoxicillin.
Final calculated dose per administration is 75 mg.
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