A nurse is conducting the admission assessment of a client who is positive for Group B Streptococcus (GBS). Which finding is of most concern to the nurse?
Continued bloody show.
Cervical dilation of 4 cm.
Contractions every 4 minutes.
Spontaneous rupture of membranes 3 hours ago.
The Correct Answer is D
Choice A rationale
Continued bloody show refers to the mucous plug mixed with a small amount of blood, which is a normal finding during labor as the cervix softens, effaces, and dilates. While the amount of bloody show is monitored, it is not the most immediate or critical concern compared to a pathway for bacterial ascent, especially in a GBS-positive client.
Choice B rationale
Cervical dilation of 4 cm indicates the client is in the active phase of the first stage of labor. Although the rate of dilation is important, a GBS-positive client at 4 cm is generally expected to progress, and this finding does not represent the highest risk compared to potential exposure from membrane rupture.
Choice C rationale
Contractions every 4 minutes indicate effective uterine activity for progression of labor, which is an expected physiological process. Monitoring contraction frequency and intensity is standard, but contractions themselves do not pose the greatest risk factor for a GBS-positive client compared to compromised integrity of the amniotic barrier.
Choice D rationale
Spontaneous rupture of membranes (SROM) 3 hours ago in a GBS-positive client significantly increases the risk of ascending infection, potentially leading to chorioamnionitis in the mother and neonatal sepsis. The GBS organism can colonize the birth canal, and once the barrier is broken for an extended period, the risk becomes acute, requiring prompt antibiotic prophylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Urinary frequency is a presumptive sign of pregnancy often caused by hormonal changes, particularly increased human chorionic gonadotropin (hCG) and progesterone, and pressure from the enlarging uterus on the bladder, leading to a reduced bladder capacity and increased renal blood flow and filtration rate.
Choice B rationale
A positive urine pregnancy test is a probable sign of pregnancy, as it is highly suggestive but not entirely conclusive. It detects the presence of human chorionic gonadotropin (hCG), which can also be elevated due to certain tumors or conditions other than a viable intrauterine pregnancy.
Choice C rationale
Breast changes, such as fullness, tenderness, and darkening of the areolae, are presumptive signs. These changes are stimulated early in pregnancy by elevated levels of estrogen and progesterone, preparing the mammary glands for lactation and causing vascular engorgement and glandular hyperplasia.
Choice D rationale
Quickening refers to the maternal perception of fetal movement, usually felt between 16 and 20 weeks gestation. Because it is a subjective sensation, it is classified as a presumptive sign; it could potentially be confused with peristalsis or gas in the abdomen.
Choice E rationale
Amenorrhea, the cessation of menstruation, is an early and very common presumptive sign of pregnancy. It is caused by the hormonal milieu, primarily the sustained production of progesterone by the corpus luteum, which prevents the shedding of the endometrial lining.
Correct Answer is ["A","D"]
Explanation
Choice A rationale
The sudden, profound drop of the FHR from 125 to 80 that persists despite basic corrective measures (repositioning, IV fluids) constitutes a nonreassuring fetal status, specifically a prolonged, severe bradycardia. The nurse must immediately notify the healthcare provider so that they can quickly assess and initiate further urgent intervention, such as preparation for delivery.
Choice B rationale
Inserting a Foley catheter is not an immediate, high-priority intervention for persistent severe fetal bradycardia. While a catheter may be used to prepare for a cesarean section, the immediate, critical step is to report the nonreassuring fetal status and prepare for rapid delivery to prevent fetal hypoxia and possible death.
Choice C rationale
Pitocin (oxytocin) is a uterine stimulant and would exacerbate the current fetal distress by increasing the frequency and intensity of uterine contractions, which further decreases utero-placental perfusion and oxygen supply to the distressed fetus. Pitocin must be discontinued, not started, in this nonreassuring scenario.
Choice D rationale
The persistent severe fetal bradycardia (FHR in the 80s) indicates a compromised fetal condition and impending hypoxia, which requires prompt resolution. If internal resuscitation efforts fail to rapidly restore a normal FHR, preparing for an immediate operative delivery, such as an emergency cesarean section, is the appropriate, life-saving measure.
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