The nurse in a prenatal unit is providing care for a patient who experienced preterm premature rupture of the membranes (PPROM) at 32 weeks' gestation.
Which assessment does the nurse consider unnecessary?
Assess for vaginal bleeding.
Monitor for signs of infection.
Check for cervical dilation.
Watch for fetal compromise.
The Correct Answer is A
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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
Numbness in the toes and heel might suggest nerve involvement but is not a typical sign of deep vein thrombosis (DVT), which involves the veins, not nerves.
Choice B rationale
Pain relieved by dorsiflexion (positive Homan's sign) is not reliable for diagnosing DVT. This symptom is outdated and not considered a definitive sign.
Choice C rationale
Spider-like and purple veins suggest superficial varicose veins, not deep vein thrombosis, which affects deeper veins and presents differently.
Choice D rationale
Swelling, redness, and warmth in the calf are classic signs of DVT due to the inflammation and obstruction of deep veins. These symptoms should prompt immediate medical evaluation and intervention. .
Correct Answer is C
Explanation
Choice A rationale
Extension of the episiotomy is not a guideline for vacuum-assisted delivery. Episiotomy extension is considered based on perineal conditions during delivery, not as a primary
guideline for vacuum procedures.
Choice B rationale
Signs of fetal compromise resolving is critical for fetal safety but isn't specific to the guidelines for a vacuum-assisted delivery. Continuous fetal monitoring assesses for compromise,
not just vacuum application.
Choice C rationale
The "three-pull" rule refers to the number of attempts allowed with the vacuum to avoid excessive force and trauma. This guideline ensures safety during the procedure, preventing
overuse of vacuum pressure.
Choice D rationale
Full anesthesia status is unrelated to the guidelines for vacuum-assisted delivery. Anesthesia choices depend on patient and procedural needs, but aren't a guideline criterion for
vacuum use.