A nurse is triaging four clients on the labor and delivery unit.
Which of the following actions should be a priority for nursing care?
Check the blood sugar of a gestational diabetic.
Assess the vaginal blood loss of a client who is recovering from a spontaneous abortion.
Assess the patellar reflexes of a client with pre-eclampsia without severe features.
Check the fetal heart rate of a client whose membranes just ruptured.
The Correct Answer is D
Choice A rationale
Checking blood sugar is important in gestational diabetes but isn't immediate priority in a triage setting compared to assessing urgent conditions that could harm the fetus or mother immediately.
Choice B rationale
Assessing vaginal blood loss post-abortion is crucial, but in the presence of ruptured membranes, fetal heart rate checks take precedence to ensure the fetus's immediate well-being.
Choice C rationale
Assessing patellar reflexes in pre-eclampsia management is significant, but immediate priority in labor and delivery triage goes to ensuring fetal safety after membrane rupture.
Choice D rationale
Checking the fetal heart rate after membrane rupture is a priority because it provides immediate information about the fetus's status and any potential complications like cord prolapse or distress.
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Correct Answer is A
Explanation
Choice A rationale
Assessing for vaginal bleeding in PPROM is generally not necessary unless there is an indication of placental issues or other complications. PPROM involves the rupture of
membranes before 37 weeks, primarily requiring monitoring for infection and fetal wellbeing rather than routine bleeding checks.
Choice B rationale
Monitoring for signs of infection is critical after PPROM because the rupture increases the risk of ascending infections. The nurse should diligently assess for fever, foul-smelling
discharge, and other signs of infection to initiate timely interventions, preserving both maternal and fetal health.
Choice C rationale
Checking for cervical dilation in PPROM is important because premature rupture of membranes can lead to preterm labor. Monitoring dilation helps determine if labor is imminent,
influencing decisions regarding maternal and neonatal care to prevent complications from premature birth.
Choice D rationale
Watching for fetal compromise is necessary following PPROM as premature rupture of membranes can lead to umbilical cord compression or other complications affecting fetal oxygenation. Continuous fetal monitoring helps detect early signs of distress, allowing timely intervention to ensure fetal safety.
Correct Answer is A
Explanation
Choice A rationale
Postpartum psychosis is a serious mental health condition that can result in delusions and hallucinations. These symptoms increase the risk of harm to the infant, so it's essential that
the mother is not left alone with the baby to ensure both their safety.
Choice B rationale
Symptoms of postpartum psychosis typically last longer than one week and require medical intervention, contrary to what is stated in this choice. Treatment usually involves
antipsychotics, mood stabilizers, and sometimes hospitalization.
Choice C rationale
Clinical response to medications can be significant in many cases, and early and aggressive treatment often leads to improvement. This statement is inaccurate and does not reflect
the current understanding of postpartum psychosis treatment.
Choice D rationale
While monitoring vital signs is essential, it is not as critical as ensuring the infant's safety given the mother’s severe mental condition. The focus should be on psychiatric
management and safety protocols rather than routine vitals alone.