QUESTION: "The nurse would assess a 26-year-old multigravida at 30 weeks' gestation with premature rupture of the membranes for symptoms of which of the following?"
CHOICES
( O ) a.) Foul-smelling amniotic fluid.
( X ) b.) Uterine prolapse.
( X ) c.) Small-for-gestational-age fetus.
( X ) d.) Tetanic uterine contractions.
RATIONALE: Although the cause of premature rupture of the membranes is unknown, it has been associated with incompetent cervix, infection, trauma, and multiple pregnancies. Therefore, assessing the client for symptoms of infection, such as foul-smelling amniotic fluid would be important. Uterine prolapse is not associated with premature rupture of the membranes. Because the client is at 30 weeks' gestation, she should be assessed for a small-for-gestational-age fetus. However, a small-for-gestational-age fetus is not related to premature rupture of membranes. Tetanic uterine contractions are associated with oxytocin administration, not with premature rupture of membranes. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
