A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment.
Which of the following laboratory tests should the nurse plan to conduct?

Rationales for Each Condition

Neonatal Abstinence Syndrome (NAS)

1. Temperature: Infants experiencing NAS often have difficulty regulating body temperature due to autonomic instability. While the newborn's temperature of 36.6°C (97.9°F) is within normal range, the use of a radiant warmer suggests challenges in maintaining thermoregulation, which is characteristic of NAS.
2. Jitteriness: Jitteriness is observed in both hypoglycemia and NAS. In NAS, it is caused by neurological excitability due to opioid withdrawal, leading to tremors and hypertonia, which improve with soothing measures such as swaddling.
3. Skin Color: Mottling is a frequent sign in neonates experiencing opioid withdrawal due to autonomic dysregulation. The absence of cyanosis or jaundice indicates that the mottling is due to withdrawal rather than an underlying pathology.
4. GI Assessment: Loose stools and hyperactive bowel sounds are typical signs of NAS, caused by increased gastrointestinal motility due to withdrawal from opioids.

Hypoglycemia

1. Jitteriness: Hypoglycemia is characterized by neuromuscular instability, leading to jitteriness. However, in this case, the newborn’s blood glucose level of 45 mg/dL is within acceptable neonatal range, making NAS a more likely explanation.
2. Temperature, Skin Color, and GI Assessment: Hypoglycemia does not typically cause mottled skin or loose stools, making these findings more consistent with NAS.

Upon reviewing the client’s medical record, the nurse determines that the client is at risk for developing choriocarcinoma and thyrotoxicosis.

Rationale for correct answers

Choriocarcinoma is a malignant form of gestational trophoblastic disease (GTD) that arises from a molar pregnancy, as evidenced by grape-like vesicles seen on ultrasound and excessively elevated beta-hCG (normal in pregnancy: up to 100,000 mIU/mL by late first trimester). This condition can lead to metastases if not diagnosed and treated promptly.

Thyrotoxicosis occurs due to excess beta-hCG, which stimulates thyroid hormone production. This is supported by the slightly elevated free T4 levels, a common feature of molar pregnancy-related hyperthyroidism.

Rationale for incorrect Response 1 options

• Preterm labor: The client is at 20 weeks with no contractions noted, and cervical changes are not reported.
• Placenta previa: Characterized by painless bright red bleeding later in pregnancy; this client has dark brown discharge consistent with molar pregnancy.
• Cardiac arrhythmia: No evidence of electrolyte abnormalities or arrhythmogenic conditions such as hyperkalemia.

Rationale for incorrect Response 2 options

• Preeclampsia: Normal blood pressure (≥140/90 mm Hg would be concerning); no proteinuria.
• Urinary tract infection: No leukocytes, nitrites, or dysuria reported.
• Hypoglycemia: Normal serum glucose levels; vomiting history does not indicate hypoglycemia.