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 ["A","B","C","D"]
Explanation
Choice A rationale
Accurate measurement of intake and output is crucial after atrial septal defect repair to detect potential fluid imbalances or kidney dysfunction. Monitoring ensures early intervention in cases of dehydration or fluid overload.
Choice B rationale
Providing uninterrupted rest promotes recovery by minimizing stress on the cardiovascular system and reducing metabolic demands post-surgery. Adequate rest also allows tissue healing and stabilizes vital parameters.
Choice C rationale
Maintaining a thermoneutral environment prevents temperature fluctuations, which could increase metabolic demand and stress the healing heart. Temperature regulation is particularly important in infants with compromised cardiac function.
Choice D rationale
Encouraging bonding supports emotional and psychological recovery for both the infant and parents. Physical closeness can improve the infant's developmental outcomes and reduce parental anxiety after surgery.
Choice E rationale
Using an incentive spirometer 10 times hourly is not appropriate for infants. Incentive spirometers are designed for cooperative patients, typically older children or adults, as they require active participation in deep-breathing exercises.
Correct Answer is C
Explanation
Choice A rationale
A history of pelvic inflammatory disease may result in complications like infertility or chronic pelvic pain but does not specifically indicate endometriosis. Endometriosis involves the ectopic implantation of endometrial tissue, unrelated to infection from PID.
Choice B rationale
An atypical Papanicolaou smear suggests cervical cell abnormalities due to infection, inflammation, or dysplasia, but it does not correlate with endometriosis, which is a distinct gynecological condition involving ectopic endometrial tissue growth.
Choice C rationale
Dysmenorrhea unresponsive to NSAIDs is a defining symptom of endometriosis. This pain results from the inflammatory response and cyclic bleeding of ectopic endometrial tissue, which can cause significant discomfort and impair quality of life.
Choice D rationale
Abdominal bloating several days before menses may be linked to hormonal fluctuations or gastrointestinal issues but is not a primary symptom of endometriosis. While some affected individuals experience bloating, it is not a diagnostic feature like severe, treatment-resistant pain. .
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