The nurse is caring for a G4P1, 31 weeks and 2 days gestation, 41-year-old patient, with premature prolonged rupture of membranes (PPROM) 7 hours after delivery. Which interventions will the nurse include in the plan of care? Select all that apply.
Facilitate an early discharge.
Discontinue oxycodone administration.
Restrict visitor time.
Provide breast pump.
Correct Answer : B,C,D
Choice A reason: Facilitating an early discharge is not appropriate in this case. Patients with PPROM require careful monitoring and management to prevent infections and other complications.
Choice B reason: Discontinuing oxycodone administration may be necessary to prevent potential adverse effects on both the patient and the baby, especially considering the patient's recent delivery and current condition.
Choice C reason: Restricting visitor time can help reduce the risk of infection, especially for a patient with PPROM and a newborn who may have a compromised immune system.
Choice D reason: Providing a breast pump is important to help the mother establish and maintain lactation, especially if the baby is premature and may have difficulty breastfeeding directly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A red blood cell count of 4.5 million/cu mm is within the normal range for pregnant women. It does not indicate an immediate concern that needs to be reported to the healthcare provider. Normal red blood cell counts help ensure adequate oxygen transport in the body.
Choice B reason: A haematocrit level of 37% is also within the normal range for pregnant women. Haematocrit measures the proportion of red blood cells in the blood, and this level does not indicate an immediate concern. It is important for maintaining proper oxygen delivery and overall blood volume.
Choice C reason: Platelets 85,000/mm3 is significantly below the normal range (150,000-450,000/mm3). Low platelet counts (thrombocytopenia) can lead to increased risk of bleeding and can be a sign of conditions like preeclampsia, HELLP syndrome, or other blood disorders. This is a critical finding that needs to be immediately reported to the healthcare provider for further evaluation and management to prevent potential complications.
Choice D reason: Haemoglobin level of 14 g/dL is within the normal range for pregnant women and indicates good oxygen-carrying capacity of the blood. It does not represent an immediate concern that would require urgent reporting to the healthcare provider. Maintaining proper haemoglobin levels is crucial for overall health and well-being.
Correct Answer is D
Explanation
Choice A reason: While some parents may choose to home school their child, this is a personal decision and not a standard recommendation for all children with Trisomy 21. Educational needs should be tailored to the individual child's abilities and preferences, and many children with Trisomy 21 attend public or private schools with appropriate support.
Choice B reason: Teaching the parents about the need for a high-fibre diet is important for overall health but is not specific to Trisomy 21. While children with Trisomy 21 may benefit from a balanced diet, the need for monthly thyroid testing is more directly related to managing their condition.
Choice C reason: Instructing the parents on the need for yearly dental visits is essential for maintaining oral health, but it is not the most critical aspect specific to Trisomy 21. Regular dental check-ups are recommended for all children, regardless of whether they have Trisomy 21.
Choice D reason: Advising the parents that the child will need monthly thyroid testing is crucial because children with Trisomy 21 are at an increased risk for thyroid disorders. Regular monitoring of thyroid function is essential for early detection and management of hypothyroidism or hyperthyroidism, which can significantly impact growth and development.
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