A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?

Choice A rationale

Monitoring the color of amniotic fluid is crucial for assessing fetal well-being, but it is not the primary concern in the case of prolonged ROM. The focus should be on preventing maternal and fetal infection.

Choice B rationale

Maternal temperature should be monitored more frequently because prolonged ROM increases the risk of infection, particularly chorioamnionitis. Early detection of fever can prompt timely intervention to prevent complications.

Choice C rationale

Deep tendon reflexes are not directly affected by prolonged ROM. Monitoring them is more relevant for conditions like preeclampsia, where neurological assessment is critical. It is not the main concern in this scenario.

Choice D rationale

Maternal blood pressure is important to monitor but is not the primary focus in the context of prolonged ROM. The main concern is the increased risk of infection, necessitating closer monitoring of maternal temperature.

Choice A rationale: Hemoglobin of 10.4 g/dL is slightly below the normal range for non-pregnant women (12-16 g/dL) but may be acceptable postpartum. Mild anemia can cause fatigue but doesn't explain the new-onset headache, dizziness, or elevated blood pressure.

Choice B rationale: Platelet count of 150,000/mm³ is within the normal range (150,000-450,000/mm³). Thrombocytopenia would be a concern if platelets were below 150,000/mm³, as it can cause bleeding, but it doesn't correlate with the client's symptoms.

Choice C rationale: New-onset headache, especially unrelieved by ibuprofen, is concerning. Postpartum preeclampsia can present with a severe headache. The headache, combined with elevated blood pressure, requires further investigation for potential complications like cerebral edema or hypertensive encephalopathy.

Choice D rationale: Vomiting yellow fluid may indicate gastrointestinal distress or bile. In the context of right upper quadrant pain and elevated blood pressure, it raises concerns for conditions like HELLP syndrome or liver involvement. Further evaluation is needed to rule out these possibilities.

Choice E rationale: Right upper quadrant pain can be a symptom of postpartum preeclampsia or HELLP syndrome, where liver enzymes are elevated. Pain in this area combined with other symptoms like headache, nausea, and elevated blood pressure warrants further investigation.

Choice F rationale: Seeing flashing lights is a potential sign of visual disturbances related to severe hypertension or preeclampsia. It can be an indication of impending eclampsia or other complications like retinal detachment or cerebral edema. This symptom must be promptly evaluated.

Choice G rationale: Elevated blood pressure (169/104 mm Hg) is a critical finding. Normal postpartum blood pressure should be below 140/90 mm Hg. Severe hypertension postpartum can lead to complications like preeclampsia, eclampsia, or stroke. Immediate medical evaluation is required.

Choice H rationale: Iron supplementation is common postpartum to address mild anemia and restore iron levels depleted during pregnancy and delivery. While important for recovery, it does not explain the new-onset headache, elevated blood pressure, or other symptoms reported by the client.