A nurse is caring for a female client, age 29, at 39 weeks of gestation in the intrapartum unit following spontaneous rupture of membranes.
Complete the following sentence by using the lists of options.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
The client is at risk for developing Intraamniotic infection as evidenced by White blood cell count.
Rationale for correct answers:
Intraamniotic infection (chorioamnionitis) is a bacterial infection of the amniotic sac often associated with prolonged rupture of membranes and labor. This client has spontaneous rupture of membranes (SROM) 1 hour ago with positive nitrazine test confirming amniotic fluid presence. The elevated white blood cell count (19,800/mm³; normal 5,000–15,000/mm³) is an early marker of infection or inflammation. The presence of group B streptococcus further increases infection risk. The amniotic fluid is moderate and clear, which is normal, so fluid characteristics alone do not indicate infection. Early identification and management of intraamniotic infection are critical to prevent maternal and fetal morbidity.
Rationale for incorrect Response 1 options:
Fetal hypoxia typically manifests as abnormal fetal heart rate patterns such as late decelerations or decreased variability, which are not present here (FHR 150/min, moderate variability). Labor dystocia refers to abnormal or slow labor progress; with 2 cm dilation and regular contractions, no evidence suggests dystocia yet. Gestational hypertension is a maternal hypertensive disorder unrelated to current rupture or WBC findings.
Rationale for incorrect Response 2 options:
Amniotic fluid characteristics (clear, moderate) are normal and not indicative of infection. Uterine tone is moderate and normal on palpation, not suggesting infection or abnormal labor. Cervical exam findings (2 cm dilation, 10% effacement) are early labor signs but do not indicate infection risk.
Take home points:
- Elevated WBC after rupture of membranes signals increased risk of intraamniotic infection.
- Clear amniotic fluid with positive nitrazine confirms membrane rupture but does not confirm infection.
- Early labor signs should be monitored for infection risk, especially with group B strep positive status.
- Differentiating infection from other labor complications like dystocia or fetal hypoxia relies on clinical signs and fetal monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Step 1 is to convert grams to milligrams. 2 g × (1000 mg ÷ 1 g) = 2000 mg.
Step 2 is to divide the total milligrams needed by the milligrams per tablet. 2000 mg ÷ 250 mg = 8 tablets. The nurse should administer 8 tablets.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale: Ensuring suction is available is critical because clients with severe preeclampsia or eclampsia are at risk for seizures that can cause airway obstruction from secretions or vomiting. Suction readiness supports immediate airway management during a seizure, preventing aspiration and maintaining oxygenation, essential in protecting maternal and fetal health.
Choice B rationale: Administering 10 L of oxygen via nasal cannula is not appropriate because nasal cannulas typically deliver oxygen up to 6 L/min; higher flows require a different delivery system like a non-rebreather mask. Also, routine high-flow oxygen is not indicated unless hypoxia is present. The client’s oxygen saturation is normal (99%), so supplemental oxygen at this rate is unnecessary and could cause discomfort or drying of mucous membranes.
Choice C rationale: Raising side rails is a safety measure to prevent injury during seizures or sudden movements caused by central nervous system irritability in preeclampsia. Elevated side rails help protect the client from falls or trauma if a seizure occurs, an essential precaution in clients with neurological symptoms such as hyperreflexia and clonus.
Choice D rationale: Placing a padded tongue blade at the bedside prepares for seizure management by preventing tongue biting and airway obstruction. The padded blade reduces the risk of oral trauma during convulsions and maintains airway patency. However, it should be used carefully to avoid airway injury or obstruction and only if a seizure occurs.
Choice E rationale: Dimming lights reduces environmental stimuli that may exacerbate neurological irritability or trigger seizures in preeclampsia/eclampsia. Bright or flashing lights can increase CNS excitation, worsening headache, visual disturbances, or seizure risk. Creating a calm, low-stimulation environment helps stabilize the client’s neurological status.
Choice F rationale: Placing the client in the supine position is contraindicated because it compresses the inferior vena cava, reducing venous return and cardiac output, potentially worsening placental perfusion. The left lateral position is preferred in hypertensive pregnancy to optimize uteroplacental blood flow and maternal hemodynamics, improving fetal oxygenation and maternal comfort.
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