A multiparous client with active herpes lesions has been admitted to the unit due to spontaneous rupture of membranes.
What action should the nurse take?

Choice C rationale

Amenorrhea, or the absence of menstruation, is often the first and most reliable sign of pregnancy. If a woman is in her childbearing years and a week or more has passed without the start of an expected menstrual cycle, she might be pregnant.

Choice A rationale

Hegar’s sign is a physical examination finding that can be indicative of pregnancy. However, it is not typically used as the primary indicator of pregnancy because it requires a pelvic examination and is less reliable than other signs such as amenorrhea.

Choice B rationale

While breast tenderness can be a symptom of early pregnancy, it is not the most reliable indicator. Many other conditions or factors, such as hormonal fluctuations related to the menstrual cycle, can also cause breast tenderness.

Choice D rationale

Morning sickness, characterized by nausea and vomiting, is a common symptom of early pregnancy. However, not all pregnant women experience morning sickness, and it can also be caused by other conditions. Therefore, it is not the most reliable indicator of pregnancy.

Choice A rationale

While it’s true that AFP results can sometimes be false readings, it’s not the most appropriate advice for the nurse to give in this situation. Simply reassuring the client without suggesting further investigation could potentially overlook a serious condition.

Choice B rationale

Discussing options for intrauterine surgical correction of congenital defects at this stage is premature. The elevated AFP level alone does not confirm the presence of congenital defects, and suggesting surgical intervention may cause unnecessary anxiety.

Choice C rationale

Informing the client that a repeat AFP test should be conducted is a reasonable suggestion. However, it’s not the most appropriate next step in this case. A repeat test would provide more information, but it wouldn’t give definitive results about the cause of the elevated AFP level.

Choice D rationale

Explaining that a sonogram should be scheduled for definitive results is the most appropriate advice. An ultrasound can provide a more detailed view of the fetus and help identify any potential issues that might have led to the elevated AFP level. This would be the most informative next step and would guide further actions based on the findings.