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?
Administer parental antibiotics
Prepare for delivery
Provide emotional support
Assess cervical dilation every 6 hours
The Correct Answer is A
A. Administer parenteral antibiotics. The primary concern with premature rupture of membranes (PROM) is the risk of infection, so administering antibiotics is crucial to prevent infection in both the mother and fetus.
B. Prepare for delivery. Without signs of labor, the focus is on preventing infection and monitoring, not immediate delivery.
C. Provide emotional support. While important, the priority intervention is preventing infection.
D. Assess cervical dilation every 6 hours. Routine cervical checks are not typically necessary unless there are signs of labor or other indications.
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Related Questions
Correct Answer is B
Explanation
A. Point of maximum impulse is shifted to the right. This is not typically associated with coarctation of the aorta, but with other cardiac abnormalities.
B. Weak or absent lower extremity pulses. Coarctation of the aorta causes narrowing of the aorta, which restricts blood flow to the lower body, leading to diminished pulses in the lower extremities.
C. Apical pulse is greater than radial pulse. This finding is not specifically related to coarctation of the aorta.
D. Systolic murmur at the left sternal border. While murmurs may be present, coarctation typically causes a murmur best heard in the back or left infraclavicular area.
Correct Answer is C
Explanation
A. Keep the newborn in a well-lit nursery: A well-lit nursery can overstimulate a preterm newborn. Preterm infants benefit more from a dim, quiet environment that mimics the womb.
B. Cluster the newborn's care activities: This helps minimize disruptions to the newborn’s rest periods, which is crucial for their growth and neurodevelopment. Clustering care reduces stress and promotes better sleep cycles.
C. Position the newborn to promote extension of muscles: Preterm infants generally benefit from a flexed position, which is more comforting and developmentally appropriate, rather than promoting muscle extension.
D. Use fingertips when calming the newborn: Using fingertips might be too stimulating for a preterm newborn. Instead, a gentle, whole-hand touch is often more comforting and less likely to cause overstimulation.
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