Physiological Adaptation Q 184
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 are the priority nursing diagnoses at this time?
Altered tissue perfusion
Risk for fluid volume deficit
High risk for hemorrhage
Risk for infection
Correct Answer: D. Risk for infection
Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn. Rupture of membranes results from a variety of factors that ultimately lead to accelerated membrane weakening. This is caused by an increase in local cytokines, an imbalance in the interaction between matrix metalloproteinases and tissue inhibitors of matrix metalloproteinases, increased collagenase and protease activity, and other factors that can cause increased intrauterine pressure.
Option A: There should be little or no alteration in perfusion after premature rupture of the membranes. Decreased tissue perfusion can be temporary, with few or minimal consequences to the health of the patient, or it can be more acute or protracted, with potentially destructive effects on the patient. When diminished tissue perfusion becomes chronic, it can result in tissue or organ damage or death.
Option B: There may be a risk for deficient fluid volume, but it is not a priority. Fluid volume deficit (FVD) or hypovolemia is a state or condition where the fluid output exceeds the fluid intake. It occurs when the body loses both water and electrolytes from the ECF in similar proportions. Common sources of fluid loss are the gastrointestinal tract, polyuria, and increased perspiration.
Option C: Hemorrhage is not a great risk in premature rupture of membranes. One of the complications of PROM is intraventricular hemorrhage. This is because blood vessels in the brain of premature infants are not fully developed, and are therefore weaker than that of term babies. Research shows that intraventricular hemorrhages (IVH) or brain bleeds are significantly reduced by steroid treatment, without an increase in either maternal or neonatal infection.