A nurse is caring for a newborn who has herpes simplex virus as a result of in utero transmission.
Which of the following actions should the nurse take?

Choice A rationale

Nausea, commonly known as "morning sickness," is a very common and normal physiological response during the first trimester of pregnancy, often attributed to hormonal changes, particularly rising levels of human chorionic gonadotropin (hCG) and estrogen. While uncomfortable, it does not typically indicate a need for a registered dietitian referral unless it leads to significant weight loss or hyperemesis gravidarum.

Choice B rationale

A 4.5 kg (10 lb) weight gain by 12 weeks of gestation is considered excessive for the first trimester. The recommended weight gain during the first trimester is typically 0.5 to 2 kg (1 to 4.5 lb). Such rapid weight gain can indicate an imbalanced diet or underlying nutritional issues that warrant evaluation and guidance from a registered dietitian to optimize maternal and fetal health.

Choice C rationale

Taking a multivitamin daily, especially one formulated for prenatal use, is a positive health behavior during pregnancy. Prenatal vitamins typically contain essential nutrients like folic acid and iron, which are crucial for fetal development and maternal health, reducing the risk of neural tube defects and iron deficiency anemia. This indicates appropriate nutritional supplementation, not a need for referral.

Choice D rationale

Constipation is a common complaint during pregnancy, often due to hormonal changes, such as increased progesterone, which slows gastrointestinal motility, and pressure from the growing uterus on the bowels. Eating prunes is a natural and effective dietary strategy to manage constipation, as they are a good source of fiber, promoting bowel regularity. This is a healthy coping mechanism and does not necessitate a dietitian referral.

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.