The nurse on the high-risk antepartal unit has received shift change report. Which client should the nurse see first?
1. Primip at 26 weeks with prolonged premature rupture of membranes experiencing chills
2. Multip at 28 weeks with premature rupture of membranes reporting leakage of clear vaginal fluid
3. Primip at 30 weeks with premature rupture of membranes due for a betamethasone injection
4. Multip at 32 weeks with prolonged premature rupture of membranes and a hemoglobin of 11.0
1
Rationale:
1. Chills indicate fever, which in turn indicates infection. Prolonged premature rupture of membranes increases the risk of maternal infection, specifically chorioamnionitis. Intrauterine infection can be life-threatening to the fetus or to a neonate. This client requires immediate intervention, including contacting the physician.
2. Premature rupture of membranes is the leakage of amniotic fluid; continued leaking of clear fluid does not indicate the development of further complications.
3. Scheduled medications are important, but when a client is experiencing complications, medications are less important.
4. Although this client has prolonged premature rupture of membranes, there is no indication of any further complications. This client is a low priority.
You might also like to view...
The clinic nurse is caring for a patient who is taking a COX-2 inhibitor and knows that this patient needs to be assessed for what? (Select all that apply.)
A) Bleeding time B) Liver function C) Altered hearing D) Gastrointestinal (GI) effects E) Water retention
A client with a nursing diagnosis of activity intolerance has developed reddened areas on both heels and his coccyx. Which of the following nursing interventions will most likely have the greatest impact on this diagnosis?
1. Ambulating him to the bathroom before returning to bed 2. Encouraging him to change position every 2 hours while in bed 3. Including active range-of-motion exercises in both AM and PM care 4. Planning a rest period after AM care but before walking to the dining room for lunch
With _____ premature ventricular contractions (PVCs), the baseline and variability are obscured.
A. Idioventricular B. Bigeminal C. Trigeminal
A nurse's presentation to patients on risk factors for oral cancer includes which fact?
a. The peak incidence oral cancer is before 40 years of age. b. Women have a higher risk than men. c. Excessive alcohol consumption is a risk factor. d. Eating a low fiber diet is a risk factor.