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

Answer and Explanation

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.

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Correct Answer is ["A","D","E","F"]

Explanation

Choice A Reason: Homelessness is a risk factor for high-risk pregnancy because it exposes the woman to various challenges and stressors that can affect her health and well-being. Homeless women may face difficulties in accessing adequate nutrition, hygiene, safety, shelter, transportation, and health care. They may also experience higher levels of violence, substance abuse, mental illness, and social isolation. These factors can increase the risk of infections, complications, preterm birth, low birth weight, and infant mortality.

Choice B Reason: Age is not a risk factor for high-risk pregnancy in this case because the woman is 22 years old, which is within the optimal age range for childbearing. The optimal age range is considered to be between 20 and 35 years old, as women in this age group tend to have fewer complications and better outcomes than women who are younger or older. Women who are younger than 20 or older than 35 are considered to have advanced maternal age or adolescent pregnancy, respectively, which are risk factors for high-risk pregnancy.

Choice C Reason: BP 110/70 is not a risk factor for high-risk pregnancy because it is within the normal range for blood pressure. The normal range for blood pressure is considered to be between 90/60 and 120/80 mmHg. Blood pressure that is too high or too low can indicate problems such as preeclampsia, eclampsia, or hypotension, which are risk factors for high-risk pregnancy.

Choice D Reason: BMI 17.5 is a risk factor for high-risk pregnancy because it indicates that the woman is underweight. BMI stands for body mass index, which is a measure of body fat based on height and weight. The normal range for BMI is considered to be between 18.5 and 24.9 kg/m2. BMI that is too low or too high can indicate problems such as malnutrition, obesity, or gestational diabetes, which are risk factors for high-risk pregnancy.

Choice E Reason: Prenatal care is a risk factor for high-risk pregnancy because it indicates that the woman has not received adequate medical attention and support during her pregnancy. Prenatal care is essential for ensuring the health and well-being of both the mother and the baby. Prenatal care involves regular visits to a health care provider who can monitor the progress of the pregnancy, screen for any complications or infections, provide education and counseling, and prescribe any necessary medications or interventions. Lack of prenatal care can increase the risk of maternal mortality, morbidity, preterm birth, low birth weight, congenital anomalies, and infant mortality.

Choice F Reason: Prenatal history is a risk factor for high-risk pregnancy because it indicates that the woman has had previous pregnancies that ended in miscarriage or stillbirth. Prenatal history can provide important information about the woman's reproductive health and potential complications that may recur or affect her current pregnancy. Previous pregnancy losses can indicate problems such as genetic abnormalities, chromosomal disorders, infections, immunological factors, hormonal imbalances, uterine abnormalities, or placental issues. These factors can increase the risk of spontaneous abortion, fetal demise, preterm birth, intrauterine growth restriction (IUGR), or placenta previa.

A. clear liquid diet B. administration of diethylstilbestrol C. total parenteral nutrition D. nothing by mouth

Correct Answer is C

Explanation

Choice A: A clear liquid diet is not appropriate for a client with hyperemesis gravidarum, which is a severe form of nausea and vomiting during pregnancy that can lead to dehydration, electrolyte imbalance, and weight loss. A clear liquid diet does not provide adequate calories, protein, vitamins, or minerals for the client and the fetus.

Choice B: Administration of diethylstilbestrol is not indicated for a client with hyperemesis gravidarum. Diethylstilbestrol is a synthetic estrogen that was used in the past to prevent miscarriage and premature birth, but it was found to cause serious adverse effects such as vaginal cancer, infertility, and birth defects in the offspring.

Choice C: Total parenteral nutrition is the correct choice because it provides a complete and balanced source of nutrients through a central venous catheter. It is used for clients who cannot tolerate oral or enteral feeding due to severe gastrointestinal disorders such as hyperemesis gravidarum. It helps to prevent malnutrition, dehydration, and ketosis in the client and the fetus.

Choice D: Nothing by mouth is not a suitable option for a client with hyperemesis gravidarum. It can worsen the condition by causing starvation, acidosis, and ketosis. It can also increase the risk of aspiration pneumonia if the client vomits.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","D","E","F"]

Explanation

A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?

Correct Answer is C

Explanation

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