A 20-year-old woman, who presents to the sexual health clinic, is concerned because approximately 7 days following intercourse with a new partner, several painful genital lesions appeared. Before the lesions appeared, she states that she had a "cold" and fever. She describes them as looking like a "blister" and notes that some have ruptured and crusted over. She is worried that her partner may have given her a sexually transmitted infection (STI) and is expressing feelings of anger.
Based on the patient's presentation, which potential condition should the nurse suspect?

Choice A rationale

The MSAFP test is primarily a screening tool for fetal anomalies, not a measure of maternal liver function, which is typically assessed by serum enzymes such as alanine transaminase (ALT) and aspartate transaminase (AST). Elevated levels of these enzymes usually indicate hepatocellular damage or disease, with normal ranges for ALT generally being < 45 U/L and AST < 35 U/L. These liver function tests are separate from fetal screening.

Choice B rationale

While alpha-fetoprotein (AFP) is produced by the fetal liver and yolk sac, the maternal serum AFP (MSAFP) test is not a direct screening test for placental function. Placental function is typically assessed via methods like non-stress tests (NSTs), biophysical profiles (BPPs), and sometimes by specific hormonal assays or Doppler blood flow studies.

Choice C rationale

The MSAFP test has no utility in determining the client's cardiac function or its ability to handle the physiological demands of pregnancy. Cardiac accommodation is usually evaluated through baseline physical assessments, possibly an electrocardiogram (ECG), or by an echocardiogram if pre-existing cardiac disease is suspected.

Choice D rationale

Maternal serum alpha-fetoprotein is a glycoprotein produced by the fetal liver and yolk sac, which crosses the placenta into the maternal circulation. Elevated levels are associated with open neural tube defects like spina bifida and anencephaly, while low levels are associated with Down syndrome. It is a key non-invasive screening tool offered between 15 and 20 weeks of gestation.

Choice A rationale: Monitoring contraction duration only once every hour is inadequate and inappropriate in the presence of variable decelerations on the fetal heart rate (FHR) tracing. Variable decelerations are abrupt drops in FHR, often caused by umbilical cord compression. The nursing priority is to act immediately to relieve the compression and improve fetal oxygenation, not to observe the uterus infrequently.

Choice B rationale: Discontinuing the oxytocin infusion is the most critical and immediate intervention for this tracing. Oxytocin increases both the frequency and intensity of contractions, which can worsen cord compression and reduce the fetus’s recovery time between contractions. Stopping the uterine stimulation is the fastest way to relieve stress on the fetus.

Choice C rationale: Slowing the oxytocin infusion is a reasonable intervention, but it is not the first step. Because the variable decelerations are recurrent and pronounced, with FHR dropping below 90 bpm, the immediate and most effective action is to discontinue the infusion entirely. This should then be followed by other intrauterine resuscitation measures, such as repositioning the client laterally.

Choice D rationale: Increasing the flow rate of the main IV fluid line (a bolus) is a common intervention during fetal distress, as it can improve maternal blood volume, placental perfusion, and fetal oxygenation. However, in this case, the primary issue is recurrent variable decelerations likely caused by cord compression worsened by contractions. Therefore, the oxytocin must be stopped first to prevent further stress on the fetus.