The nurse knows that the third stage of labor has a high risk for which of the following complications?

Rationale for correct condition: The client is likely experiencing PPROM, as evidenced by the sudden gush of clear fluid and continued light leakage, confirmed by fluid pooling in the vaginal vault that tested positive for ferning. PPROM can lead to preterm labor and increased risk of infection. The absence of contractions or bleeding, and the mild lower abdominal discomfort, further supports this diagnosis.

Rationale for actions: Administering prophylactic antibiotics helps prevent infection, which is a significant risk with PPROM. Educating the client on kick counts ensures monitoring of fetal well-being. Preparing for an emergent C-section is not immediately necessary as the cervix is closed. Providing IV fluids for hypotension is not applicable here as blood pressure is elevated. Discharging the client with follow-up in one week is inappropriate given the risk of infection and preterm labor.

Rationale for parameters: Monitoring signs of infection is crucial, as PPROM increases infection risk. Maternal blood pressure trends must be watched due to elevated readings, suggesting possible complications. Meconium-stained amniotic fluid, while concerning, is not present. Maternal platelet levels and fundal height measurements do not directly address the current risks associated with PPROM.

Rationale for incorrect conditions: Placental abruption typically involves abdominal pain and bleeding, which are absent. Preeclampsia involves hypertension and proteinuria, but no significant proteinuria is present. Oligohydramnios involves decreased amniotic fluid, but the client reports clear fluid leakage indicating rupture of membranes.

• Blood pressure 160/105 mm Hg: This is abnormal as it is significantly elevated, which is a key indicator of preeclampsia.
• Reflexes 3+: This is abnormal and indicates hyperreflexia, often seen in preeclampsia.
• Platelet count 140,000/mm³: This is abnormal since it is on the lower end, suggesting mild thrombocytopenia, common in preeclampsia.
• Temperature 37.2°C: This is normal for a pregnant individual.
• Oxygen saturation 97%: This is normal, indicating adequate oxygenation.