A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which findings would lead the nurse to suspect that the woman is developing an infection? Select all that apply.
Cloudy malodorous fluid
Abdominal tenderness
Fetal bradycardia
Elevated maternal pulse rate
Decreased C-reactive protein levels
Correct Answer : A,B,C,D
Choice A Reason: This is correct because cloudy malodorous fluid indicates that the amniotic fluid is contaminated with bacteria or other microorganisms that can cause infection in the woman or the fetus. Normally, amniotic fluid is clear and odorless.
Choice B Reason: This is correct because abdominal tenderness suggests that the woman has inflammation or irritation of the uterus or other pelvic organs due to infection. Abdominal tenderness can also be accompanied by cramping, pain, or fever.
Choice C Reason: This is correct because fetal bradycardia, which is a slow fetal heart rate below 110 beats per minute, indicates that the fetus is experiencing distress or hypoxia due to infection. Fetal bradycardia can be detected by electronic fetal monitoring or Doppler device.
Choice D Reason: This is correct because elevated maternal pulse rate, which is a heart rate above 100 beats per minute, indicates that the woman has an increased metabolic demand or systemic inflammation due to infection. Elevated maternal pulse rate can also be caused by dehydration, anxiety, or pain.
Choice E Reason: This is incorrect because decreased C-reactive protein levels do not indicate infection. C-reactive protein (CRP) is a protein that is produced by the liver in response to inflammation or infection. Increased CRP levels can be a sign of infection, but decreased CRP levels can be normal or indicate other conditions such as liver disease or malnutrition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Hemodilution of pregnancy is a normal physiological phenomenon that occurs when the plasma volume increases more than the red blood cell mass, resulting in a lower hemoglobin concentration. The normal hemoglobin range for pregnant women in the second trimester is 10.5 to 14 g/dL.
Choice B: A multiple gestation pregnancy may cause a higher hemoglobin level due to increased erythropoietin production by the placenta. The normal hemoglobin range for pregnant women with twins in the second trimester is 12 to 16 g/dL.
Choice C: Greater-than-expected weight gain is not related to hemoglobin level. Weight gain during pregnancy depends on various factors such as pre-pregnancy weight, nutrition, activity level, and fetal growth.
Choice D: Iron-deficiency anemia is a condition where the hemoglobin level is below the normal range due to inadequate iron intake or absorption, blood loss, or increased iron demand. The signs and symptoms of iron-deficiency anemia include fatigue, pallor, weakness, shortness of breath, and pica.
Correct Answer is ["415"]
Explanation
To calculate the amount of NG drainage, the nurse should subtract the amount of irrigation fluid from the amount of fluid in the NG canister. The irrigation fluid is not part of the drainage, but rather a way to keep the NG tube patent and prevent clogging.
The amount of irrigation fluid is 30 mL x 2 = 60 mL.
The amount of fluid in the NG canister is 475 mL.
Therefore, the amount of NG drainage is 475 mL - 60 mL = 415 mL.
The answer should be rounded to the nearest whole number and use a leading zero if it applies. Do not use a trailing zero.
Therefore, the final answer is 415 mL.
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