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NurseDive Free Nursing Practice Question
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?
A. Administer parental antibiotics
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
Prepare for delivery. Without signs of labor, the focus is on preventing infection and monitoring, not immediate delivery.
C. Provide emotional support
Provide emotional support. While important, the priority intervention is preventing infection.
D. Assess cervical dilation every 6 hours
Assess cervical dilation every 6 hours. Routine cervical checks are not typically necessary unless there are signs of labor or other indications.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 209 Reproductive Health Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
Which of the following factors would the nurse identify as risk factors for abuse in children? (Select All that Apply.)
A. Substance use
Substance use. Parents or caregivers who use substances are more likely to abuse children due to impaired judgment and increased stress levels.
B. Extreme stress
Extreme stress. High levels of stress in the family can increase the risk of child abuse as it can lead to frustration and inappropriate coping mechanisms.
C. High socioeconomic background
High socioeconomic background. This is not typically associated with increased risk of child abuse; abuse can occur across all socioeconomic levels, but certain stressors are more prevalent in lower socioeconomic contexts.
D. Strong support system
Strong support system. A strong support system typically acts as a protective factor against child abuse by providing resources and emotional support to caregivers.
E. Prematurity
Prematurity. Premature infants often have increased care needs, which can lead to parental stress and potential abuse.
F. Chronic illness
Chronic illness. Children with chronic illnesses may require more care, leading to caregiver stress and higher risk of abuse.
Full Explanation
A. Substance use. Parents or caregivers who use substances are more likely to abuse children due to impaired judgment and increased stress levels.
B. Extreme stress. High levels of stress in the family can increase the risk of child abuse as it can lead to frustration and inappropriate coping mechanisms.
C. High socioeconomic background. This is not typically associated with increased risk of child abuse; abuse can occur across all socioeconomic levels, but certain stressors are more prevalent in lower socioeconomic contexts.
D. Strong support system. A strong support system typically acts as a protective factor against child abuse by providing resources and emotional support to caregivers.
E. Prematurity. Premature infants often have increased care needs, which can lead to parental stress and potential abuse.
F. Chronic illness. Children with chronic illnesses may require more care, leading to caregiver stress and higher risk of abuse.
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?
A. Pain
Pain. Pain is the hallmark symptom of a sickle cell crisis due to the vaso-occlusion of sickled red blood cells blocking blood flow and causing ischemia in various tissues and organs.
B. High fever
High fever. While fever can occur if there is an associated infection, it is not a primary feature of sickle cell crisis.
C. Bradycardia
Bradycardia. Sickle cell crisis can cause tachycardia due to pain and stress, but not bradycardia.
D. Constipation
Constipation. This is not a typical symptom associated with a sickle cell crisis.
Full Explanation
A. Pain. Pain is the hallmark symptom of a sickle cell crisis due to the vaso-occlusion of sickled red blood cells blocking blood flow and causing ischemia in various tissues and organs.
B. High fever. While fever can occur if there is an associated infection, it is not a primary feature of sickle cell crisis.
C. Bradycardia. Sickle cell crisis can cause tachycardia due to pain and stress, but not bradycardia.
D. Constipation. This is not a typical symptom associated with a sickle cell crisis.
A nurse is assessing a postmature infant. Which of the following findings would the nurse expect? (Select All that Apply.)
A. Vernix in the folds and creases
Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails
Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo
Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin
Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet
Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex
Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.
Full Explanation
A. Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.