Author Question: The nurse on the high-risk antepartal unit has received the shift change report. Which patient ... (Read 92 times)

EY67 · **on:** Jun 27, 2018

The nurse on the high-risk antepartal unit has received the shift change report. Which patient 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

Question 2

The client with an abnormal quadruple screen is scheduled for an ultrasound. Which statement indicates that the client understands the need for this additional antepartal fetal surveillance?

1. After the ultrasound, my partner and I will decide how to decorate the nursery.
2. During the ultrasound we will see which of us the baby looks like most.
3. The ultrasound will show whether there are abnormalities with the baby's spine.
4. The blood test wasn't run correctly, and now we need to have the sonogram.

Dinolord · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

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 patient requires immediate intervention, including contacting the physician.
Rationale 2: Premature rupture of membranes is the leakage of amniotic fluid; continued leaking of clear fluid does not indicate the development of further complications.
Rationale 3: Scheduled medications are important, but when a patient is experiencing complications, medications are less important.
Rationale 4: Although this patient has prolonged premature rupture of membranes, there is no indication of any further complications. This patient is a low priority.

Answer to Question 2

3
Explanation: 3. Ultrasound is used to detect neural tube defects. An abnormal serum quadruple screen is not the result of a lab error, and can indicate either an open neural tube defect or trisomy 18 or 21.