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 B
Explanation
Choice A rationale
Consuming 27 mg of iron daily is within the recommended intake for pregnant individuals, which is typically around 27 mg per day. Iron is crucial for fetal growth and preventing maternal anemia, and this intake level supports healthy pregnancy outcomes, indicating a reduced risk factor.
Choice B rationale
Consuming 300 mg of caffeine daily is considered a high-risk lifestyle factor during pregnancy. High caffeine intake is associated with an increased risk of miscarriage, preterm birth, and low birth weight infants. The recommended limit for pregnant individuals is generally below 200 mg per day to mitigate these risks.
Choice C rationale
Consuming 3 L (101 oz) of water daily is a healthy practice during pregnancy. Adequate hydration is essential for maintaining blood volume, amniotic fluid levels, and preventing constipation and urinary tract infections. This intake level supports maternal and fetal health.
Choice D rationale
Consuming 400 mcg of folate daily is the recommended intake for pregnant individuals, particularly in the periconceptional period. Folic acid supplementation significantly reduces the risk of neural tube defects in the fetus, promoting a healthy pregnancy outcome and indicating a reduced risk factor.
Correct Answer is B
Explanation
Choice A rationale
Group B Streptococcus (GBS) screening is typically performed much later in pregnancy, usually between 35 and 37 weeks of gestation. This screening is crucial for identifying carriers and administering prophylactic antibiotics during labor to prevent vertical transmission to the newborn, which can cause severe infections like sepsis or meningitis.
Choice B rationale
Human immunodeficiency virus (HIV) screening is a standard diagnostic test offered to all pregnant clients during their first prenatal visit, typically around 12 weeks of gestation. Early detection allows for timely interventions, such as antiretroviral therapy, to reduce the risk of mother-to-child transmission and improve maternal health outcomes.
Choice C rationale
Chorionic villus sampling (CVS) is an invasive diagnostic procedure performed earlier in pregnancy, usually between 10 and 13 weeks of gestation, but it is not a routine screening test. It is typically offered to clients at high risk for genetic disorders due to family history, advanced maternal age, or abnormal prenatal screening results.
Choice D rationale
Cervical cone biopsy is a diagnostic and therapeutic procedure used to remove a cone-shaped piece of tissue from the cervix, typically to evaluate or treat abnormal cervical cells. It is not a routine diagnostic test during a normal prenatal visit and is usually performed prior to pregnancy or if there are specific gynecological concerns.
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