Author Question: The nurse has admitted a patient to the high-risk OB unit with preterm premature rupture of the ... (Read 61 times)

bcretired · **on:** Jun 28, 2018

The nurse has admitted a patient to the high-risk OB unit with preterm premature rupture of the membranes. After obtaining maternal vital signs and the fetal heart rate, which action should the nurse do next?

A.
Assess for coping skills in the woman and her partner.
B.
Attach the woman to continuous electronic fetal monitoring.
C.
Consult social work for diversionary activities to enhance bedrest.
D.
Prepare to administer antibiotics for presumed chorioamnionitis.

Question 2

A nurse is caring for a pregnant woman admitted to the high-risk OB unit. Which finding indicates to the nurse that outcomes for a priority nursing diagnosis have been met?

A.
Patient can list community resources available for her after childbirth.
B.
Patient describes skills she and partner use for dealing with stress.
C.
Patient states that with next pregnancy, she will obtain consistent prenatal care.
D.
Patient's blood pressure is 128/62 mm Hg without orthostatic changes.

katara · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B
Management of premature rupture of the membranes consists of prolonged maternal and fetal monitoring and modified bedrest. The nurse should attach the fetal monitor to the patient. In high-risk pregnancies, coping skills are often exhausted, and the nurse would do well to assess the state of coping in this patient, but this does not take priority. Providing diversionary activities would help enhance the bedrest experience, but, again, this does not take priority. There is no indication that the woman has chorioamnionitis, although it is a common cause of premature rupture of membranes. If diagnostic data indicate an infection, an antibiotic would be appropriate at that time.

Answer to Question 2

ANS: D
All options show that outcomes for important nursing diagnoses for a high-risk pregnancy have been met. However, physical needs take priority over psychosocial needs, so describing community resources and coping skills are not the most important. Prenatal care is important to help prevent adverse outcomes, but the patient is describing actions she intends to take for a subsequent, not current, pregnancy. For physical needs, airway, breathing, and circulation take priority. A stable blood pressure without orthostatic changes demonstrates hemodynamic stability and shows that outcomes for the diagnosis of risk for deficient fluid volume have been met.