Question

The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time?

A) Altered tissue perfusion
B) Risk for fluid volume deficit
C) High risk for hemorrhage
D) Risk for infection

Answer 1

The priority nursing diagnosis for a woman who had prolonged ruptured membranes prior to delivery is 'risk for infection.' This condition increases the likelihood of infection for both the mother and newborn, necessitating careful monitoring and preventive care.

Step-by-step explanation:

The priority nursing diagnosis for a woman who had ruptured membranes for 36 hours before delivery and is now 2 hours postpartum is risk for infection. The prolonged period of ruptured membranes exposes both the mother and the newborn to potential infections due to the longer time that the normally sterile environment within the amniotic sac has been open to the external environment, including potential pathogens.

Preterm premature rupture of membranes (PPROM) is associated with an increased risk of infection, calling for vigilant monitoring and prophylactic treatment to minimize complications. Postpartum care should include assessing the mother for signs of infection, such as fever, foul-smelling lochia, and tachycardia. Additionally, proper hygiene, frequent handwashing, and sterile techniques during any postpartum examinations or interventions are essential preventative measures.

It's also critical that health care providers examine the expelled placenta and fetal membranes to ensure they are intact. Any retained fragments could increase the risk of infection and postpartum hemorrhage. Effective management of the postpartum period, including promoting uterine contractions through breastfeeding, can help to reduce the risk of hemorrhage and infection.