# 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?

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> subject: Maternal Newborn Health

## 문제

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.

## 보기

1. Encourage the client to ambulate to promote labor progression
2. Perform a sterile vaginal examination to assess cervical dilation
3. Position the client in bed rest with continuous fetal monitoring **✔ 정답**
4. Administer a warm shower to promote comfort and relaxation

**정답: 3**

## 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.

## 심화 해설

Clinical Reasoning and Priority Setting

The client presents with premature rupture of membranes (PROM) at 32 weeks gestation. While the initial assessment findings—clear, odorless fluid, a fetal heart rate of 140 bpm with good variability, and an absence of contractions—are reassuring, the priority is to mitigate the most immediate risks to the fetus. PROM is a condition resulting from a weakening of the chorioamniotic membranes due to infectious, inflammatory, or mechanical processes [1]. Once the protective barrier is breached, the sterile intrauterine environment is compromised, creating a direct pathway for ascending infection. The most critical and immediate threats are umbilical cord prolapse and chorioamnionitis, both of which can lead to severe neonatal morbidity and mortality, including preterm birth complications [1][3]. Therefore, interventions must focus on continuous fetal surveillance and minimizing cord compression.

Analysis of the Correct Answer (Option 3)

Positioning the client on bed rest with continuous fetal monitoring is the correct priority intervention. Bed rest, often in a lateral or semi-Fowler's position, reduces the pressure of the presenting fetal part on the cervix, which in turn decreases the risk of umbilical cord compression or occult prolapse with every intermittent leak of fluid. Continuous electronic fetal monitoring is essential to immediately detect signs of cord compression, such as variable or prolonged decelerations, which are the hallmark of fetal distress in this scenario. This approach directly addresses the highest-priority physiological risks—infection and cord accident—while providing a baseline for ongoing assessment, aligning with the core principles of PROM management to safeguard the fetus from preterm birth complications [1][3].

Analysis of Incorrect Options

- Option 1: Encourage ambulation. Ambulation is contraindicated with a confirmed or suspected PROM, especially when the presenting part is not yet engaged. Upright positions and walking increase the gravitational force on the fetal head and the pressure gradient, significantly elevating the risk of a sudden umbilical cord prolapse, a life-threatening obstetric emergency [1]. While labor dance is an emerging intervention studied for term PROM to manage anxiety and labor progression, its safety and efficacy in a preterm gestation with ongoing fluid leakage have not been established, and it would be unsafe to initiate without direct provider guidance and continuous monitoring [2].

- Option 2: Perform a sterile vaginal examination. A digital vaginal examination is strictly avoided unless absolutely necessary and ordered by a provider in the setting of active labor or imminent delivery. Every unnecessary vaginal examination introduces vaginal flora into the cervical os, dramatically increasing the risk of introducing pathogens and accelerating the development of chorioamnionitis, a primary driver of morbidity in PROM [1]. Cervical assessment should be performed visually via sterile speculum examination to confirm pooling, ferning, and nitrazine test results, not digitally.

- Option 4: Administer a warm shower. While comfort is a valid nursing concern, it is not the priority in the acute management phase of preterm PROM. Allowing the client to shower involves ambulation, which presents the same risk of cord prolapse as Option 1. Furthermore, any activity that delays the initiation of continuous fetal monitoring and a thorough baseline assessment is unsafe. Comfort measures can be implemented only after the client is on a monitor, the fetal status is confirmed to be stable, and cord prolapse has been ruled out.

## 임상 시나리오

Clinical Management of Preterm PROM (32 Weeks)

Immediate Priorities

Upon confirming PROM, the immediate priority is to initiate continuous electronic fetal monitoring and maintain the patient on strict bed rest. This facilitates early detection of non-reassuring fetal heart patterns, such as variable decelerations indicative of cord compression, which is a life-threatening emergency. Bed rest, ideally in a lateral position, helps minimize further loss of amniotic fluid and reduces pressure on the umbilical cord.

Infection Prevention

The protective barrier of the amniotic sac is lost, creating a direct pathway for ascending infection. To reduce the risk of chorioamnionitis and neonatal sepsis, digital vaginal examinations should be strictly limited. A single sterile speculum examination may be performed by an experienced provider to confirm rupture, assess dilation, and obtain cultures, but repetitive exams are contraindicated. Monitor maternal vital signs closely for fever, fetal tachycardia, and uterine tenderness.

Antenatal Corticosteroids and Latency

At 32 weeks gestation, the primary goal is to prolong the pregnancy to allow for fetal lung maturation, provided there are no signs of infection, placental abruption, or non-reassuring fetal status. Administer a course of antenatal corticosteroids (e.g., betamethasone) to accelerate fetal lung development and reduce the risk of respiratory distress syndrome. The therapeutic window for maximum benefit is 24 hours after the first dose.

Ongoing Assessment

Continuously monitor for signs of labor, infection, or fetal distress. Document the color, amount, and odor of any ongoing fluid loss. Perform non-stress tests at least daily. Educate the patient on the importance of reporting any change in fluid color (especially green or brown), onset of contractions, fever, or decreased fetal movement, as these may signal infection or cord compromise requiring urgent intervention.

## 핵심 개념

- **Premature Rupture of Membranes** — Premature rupture of membranes. A condition where the amniotic sac ruptures before labor begins. If it occurs before 37 weeks of pregnancy, it is classified as preterm PROM (Preterm PROM, PPROM).
- **Chorioamnionitis** — Chorioamnionitis. Bacterial infection of the amniotic membrane and umbilical cord. A major complication after PROM, presenting with maternal fever, uterine tenderness, foul-smelling vaginal discharge, etc.
- **Umbilical Cord Prolapse** — Umbilical cord prolapse. An emergency situation where the umbilical cord slips into the vagina ahead of the presenting part of the fetus after the rupture of membranes. It can block fetal blood flow and be life-threatening.
- **Fetal Heart Rate (FHR) Monitoring** — Fetal heart rate monitoring. After PROM, continuous monitoring is essential and is used to detect early signs of fetal distress (loss of variability, bradycardia, severe accelerations, etc.).
- **Bed Rest** — Bed rest. As part of PROM management, it is prescribed to reduce the risk of cord prolapse, minimize amniotic fluid loss, and manage infection risk.

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