A woman who is 32 years old and 35 weeks pregnant has had rupture of membranes for eight hours and is 4 cm dilated. Since she is a candidate for infection, the nurse should include which of the following in the care plan?
a. Universal precautions.
b. Oxytocin administration.
c. Frequent temperature monitoring.
d. More frequent vaginal examinations.
Answer C.
Universal precautions are necessary for all clients but a specific assessment of the client’s temperature will give an indication the client is becoming infected. Oxytocin may be needed to induce labor if it is not progressing, but it is not done initially.Temperature elevation will indicate beginning infection. This is the most important measure to help assess the client for infections, since the lost mucous plug and the ruptured membranes increase the potential for ascending bacteria from the reproductive tract. This will infect the fetus, membranes, and uterine cavity. More frequent vaginal examinations are not recommended, as frequent vaginal exams can increase chances of infection.
a. Universal precautions.
b. Oxytocin administration.
c. Frequent temperature monitoring.
d. More frequent vaginal examinations.
Answer C.
Universal precautions are necessary for all clients but a specific assessment of the client’s temperature will give an indication the client is becoming infected. Oxytocin may be needed to induce labor if it is not progressing, but it is not done initially.Temperature elevation will indicate beginning infection. This is the most important measure to help assess the client for infections, since the lost mucous plug and the ruptured membranes increase the potential for ascending bacteria from the reproductive tract. This will infect the fetus, membranes, and uterine cavity. More frequent vaginal examinations are not recommended, as frequent vaginal exams can increase chances of infection.
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