At 20-weeks gestation, a client who has gained 20 pounds (9.1 kg) during this pregnancy tells the nurse that she is feeling fetal movement.
Fundal height measurement is 20 cm, and the client’s only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation?

Choice A rationale

Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.

Choice B rationale

An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.

Choice C rationale

Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.

Choice D rationale

Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.

Choice A rationale

Bright red bleeding in the third trimester of a pregnancy with an Rh-negative mother is an obstetric emergency and warrants the highest priority. The immediate assessment of the fetal heart rate (FHR) and the mother's contraction pattern is crucial. The nurse must determine if the bleeding is caused by conditions such as placental abruption or placenta previa, both of which are life-threatening for the mother and the fetus.

Choice B rationale

While a sterile vaginal examination may eventually be necessary to diagnose the cause of bleeding, it is not the immediate priority. Assessment of fetal well-being and maternal status takes precedence. Additionally, performing a vaginal examination increases the risk of further hemorrhage and potential infection.

Choice C rationale

Leopold maneuvers are used to determine fetal presentation and position, but they are not the priority intervention in this scenario. The nurse's main concern is stabilizing the mother and assessing for signs of fetal distress.

Choice D rationale

Assessing the woman's Rh and Coombs status for RhoGam administration is important. Still, it is not the most immediate priority in this life-threatening situation. The priority is to assess fetal well-being and stabilize the mother. If placental abruption is suspected, RhoGam administration may not be indicated.