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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Liver function tests, while important for identifying hepatic disorders, are not directly associated with polycystic ovarian syndrome (PCOS). PCOS is primarily an endocrine disorder affecting reproductive hormones, not liver function.

Choice B rationale

Blood urea nitrogen (BUN) is used to assess renal function but is not typically relevant for PCOS. PCOS does not inherently affect kidney function, making this test unnecessary in routine monitoring for this condition.

Choice C rationale

Thyroid-stimulating hormone levels are assessed to rule out thyroid dysfunction, which can present with similar symptoms to PCOS. However, thyroid issues are not caused by PCOS and monitoring TSH is not central to PCOS management.

Choice D rationale

Serum glucose levels are critical in PCOS management due to the increased risk of insulin resistance and type 2 diabetes. Monitoring these levels helps to manage glucose metabolism and prevent complications, making it a key parameter in care for PCOS patients.

A. Positive rubella serum antibody titer. B. Blood pressure 144/94 mmHg in left arm. C. Copious leukorrhea. D. O negative blood type.

Correct Answer is B

Explanation

Choice A rationale

A positive rubella serum antibody titer indicates immunity to rubella infection, which is protective during pregnancy. It is not an abnormal finding and does not require immediate reporting. Rubella immunity is important to prevent congenital rubella syndrome in the fetus, a severe condition causing defects such as deafness or cardiac anomalies.

Choice B rationale

Blood pressure of 144/94 mmHg is elevated and indicates gestational hypertension, which could progress to preeclampsia if not managed. Preeclampsia can lead to complications such as eclampsia, placental abruption, or maternal and fetal mortality. Normal blood pressure during pregnancy is less than 140/90 mmHg, making this finding critical to report.

Choice C rationale

Copious leukorrhea is a common physiological change in pregnancy due to increased estrogen levels and vascularity. It is usually benign and protective, preventing infections by maintaining a mildly acidic environment in the vagina. This finding does not warrant immediate concern unless associated with infection symptoms.

Choice D rationale

An O-negative blood type requires administration of Rh immunoglobulin to prevent Rh isoimmunization, but this is routinely managed in pregnancy. It is not an urgent issue unless there are concerns about fetomaternal hemorrhage or alloimmunization, which could harm an Rh-positive fetus.

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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?

Nursing Test Bank

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Correct Answer is B

Explanation

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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?