A 25-year-old pregnant client at 32 weeks gestation presents to the labor and delivery unit with a sudden gush of clear fluid from the vagina 2 hours ago. The nurse confirms premature rupture of membranes (PROM). Which nursing intervention should be the priority?
The client reports feeling wet and continues to have intermittent leaking of clear, odorless fluid. Fetal heart rate is 140 bpm with good variability, and the client denies contractions or abdominal pain.
1Encourage the client to ambulate to promote labor progression
2Perform a sterile vaginal examination to assess cervical dilation
3Position the client in bed rest with continuous fetal monitoring✓ 정답
4Administer a warm shower to promote comfort and relaxation
해설
Priority is preventing infection and monitoring fetal well-being. Bed rest with continuous fetal monitoring addresses cord prolapse risk and early detection of complications. Other options (ambulation, vaginal exam, warm shower) increase infection risk or are less urgent.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with Premature Rupture of Membranes (PROM) at 32 weeks gestation. PROM is the rupture of the amniotic sac before the onset of labor. The primary risks are intrauterine infection (chorioamnionitis) and cord prolapse (if the presenting part is not engaged). The priority is to minimize these risks while closely monitoring the fetus.
Answer Rationale: Key Point! The correct priority is bed rest with continuous fetal monitoring. This intervention directly addresses the two major risks:
1. Prevents Cord Prolapse: Keeping the patient supine or in a lateral position reduces the risk of the umbilical cord slipping past the presenting part if the membranes are ruptured and the head is not engaged.
2. Enables Early Detection: Continuous monitoring allows for immediate detection of fetal distress (e.g., variable decelerations suggesting cord compression) or signs of infection (e.g., maternal tachycardia, fetal tachycardia).
3. Minimizes Infection Risk: Bed rest reduces the introduction of bacteria from the perineum into the cervix.
Distractor Analysis:
Watch out for confusion! Option ①, encouraging ambulation, is contraindicated in PROM due to the risk of cord prolapse. Ambulation is typically encouraged in early, intact labor to promote progression.
Option ②, performing a sterile vaginal exam (SVE), is generally avoided in PROM unless the patient is in active labor or delivery is imminent. Each exam increases the risk of ascending infection. The nurse should confirm PROM via sterile speculum exam (to visualize pooling) and nitrazine/ferning tests, not a digital exam.
Option ④, administering a warm shower, increases the risk of infection by introducing water and potential pathogens into the vagina. Tub baths are also contraindicated for the same reason after membrane rupture.
Related Concepts: Management of PROM depends on gestational age. At 32 weeks (preterm), the goal is often to prolong the pregnancy with hospitalization, antibiotics (to prevent Group B Strep and delay onset of labor), and corticosteroids (to accelerate fetal lung maturity), unless there are signs of infection, fetal distress, or active labor.Nursing Clinical Practice GuideClinical Scenario: You are the nurse in triage. A young pregnant patient arrives stating, "My water broke at home, and I'm still leaking." She is anxious but stable. Your initial actions set the stage for her entire management plan.
Nursing Intervention Strategy:
Immediate Assessment & Safety: Place the patient on bed rest. Apply continuous external fetal monitoring (EFM) to obtain a baseline fetal heart rate (FHR) and assess for variability and decelerations. Monitor maternal vital signs, especially temperature (for infection).
Confirm PROM: Use a sterile speculum exam (not digital) to observe for pooling of amniotic fluid in the posterior vagina. Perform nitrazine paper test (turns blue/greenish-blue with alkaline amniotic fluid) and fern test (microscopic crystallization). Document the color, odor, and amount of fluid.
Ongoing Care & Monitoring: Maintain strict intake and output. Monitor for signs of labor (contractions) and infection (maternal fever, fetal tachycardia, uterine tenderness, foul-smelling discharge). Administer antibiotics and corticosteroids as prescribed for preterm PROM.
Patient Education: Educate the patient on the importance of bed rest, monitoring for signs of infection or labor, and avoiding anything in the vagina (no tampons, douching, or sexual intercourse).
Patient Safety and Precautions: The cardinal rule is nothing in the vagina to prevent infection. Be vigilant for signs of cord prolapse—a sudden, severe variable deceleration or bradycardia on the monitor. If suspected, immediately place the patient in Trendelenburg or knee-chest position, administer oxygen, and prepare for an emergency cesarean section.
Prescribed to prolong latency period (time from ROM to delivery) and prevent GBS infection. Administer on time, monitor for allergic reactions.
Corticosteroids (e.g., Betamethasone)
Given to accelerate fetal lung maturity. Typically two doses 24 hours apart. Monitor maternal blood glucose as steroids can cause hyperglycemia.
Tocolytic Agents (if labor begins)
May be used briefly to delay labor to allow for steroid effect. Monitor for maternal side effects like tachycardia (with terbutaline) or pulmonary edema.
A Word from Your Senior Nurse
"In labor and delivery, PROM is one of those 'stop and think' moments. Your first instinct might be to check dilation, but you have to fight that instinct to protect your patient and her baby. Remember: Bed rest, monitor, and keep it sterile. Your calm, knowledgeable response reassures the terrified mother that she's in good hands. On the NCLEX, they love to test if you know the 'why' behind the 'don't do'—like why no vaginal exams. Connect it to the patho: broken barrier + introduction of bacteria = risk of chorioamnionitis. That kind of thinking makes the answer clear."
Premature Rupture of Membranes — Rupture of the amniotic sac before the onset of labor at any gestational age.
Chorioamnionitis — An intrauterine infection of the fetal membranes and amniotic fluid, a major risk of PROM.
Cord Prolapse — A obstetric emergency where the umbilical cord descends through the cervix ahead of the fetal presenting part, often after ROM, leading to cord compression and fetal hypoxia.
Nitrazine Test — A bedside test using pH paper to detect amniotic fluid (alkaline, turns paper blue) versus vaginal secretions or urine (acidic).
Variable Decelerations — Abrupt, transient decreases in fetal heart rate on the monitor, often indicating umbilical cord compression—a critical sign to watch for after PROM.