The RN interprets the following external fetal monitoring strip as:

Choice A rationale

Administering oxytocin is not appropriate at this stage since the fetal head at a +5 station indicates imminent delivery.

Choice B rationale

Applying fundal pressure is not recommended and can cause complications such as uterine rupture or maternal injury.

Choice C rationale

Suctioning the mouth of the infant at the perineum should be done only after the head is delivered to clear airway obstructions.

Choice D rationale

Observing for the presence of a nuchal cord is crucial as it can cause complications during delivery, requiring immediate attention.

Complete the Sentence The priority intervention for the client with preterm premature rupture of membranes is to administer corticosteroids and administer prophylactic antibiotics.

Rationale for correct responses:

1. Administer corticosteroids: This is necessary to promote fetal lung maturity, which is crucial given the gestational age of 34 weeks.
2. Administer prophylactic antibiotics: This helps prevent maternal and fetal infection due to the rupture of membranes.

Rationale for incorrect responses:

1. Initiate tocolytic therapy: This is not the priority as the client is not currently experiencing contractions.
2. Prepare for immediate delivery: Immediate delivery is not indicated unless there are signs of fetal distress or maternal complications.
3. Perform digital cervical examination: This increases the risk of infection and is contraindicated in cases of ruptured membranes.
4. Administer Rh immunoglobulin: This is important but not the primary immediate intervention compared to corticosteroids and antibiotics.
5. Discharge the client for outpatient follow-up: This is inappropriate due to the need for close monitoring and prevention of infection.
6. Perform a biophysical profile: While useful, this is not a priority intervention compared to administering corticosteroids and antibiotics.