A nurse at a provider’s office is caring for a 24-year-old female client.

Exhibits

Complete the following sentence by using the lists of options.
The nurse should prepare to reinforce teaching with the client about a

dropdown

with a prescription of

dropdown

.

✅ Anticipated Interventions – Rationales

• Encourage frequent ambulation Ambulation can promote labor progression in clients with stable vital signs, reassuring fetal status, and no contraindications such as active bleeding or abnormal fetal presentation.
• Check client’s temperature every hour After rupture of membranes, the risk of ascending infection increases. Hourly temperature monitoring helps detect early signs of chorioamnionitis.
• Obtain CBC blood sample A baseline complete blood count is useful to assess for infection (e.g., elevated white blood cells) or anemia, especially in the setting of ruptured membranes.
• Check FHR every 30 min Intermittent fetal heart rate monitoring is appropriate in early labor for low-risk clients. It ensures fetal well-being and detects early signs of distress.

⚪ Nonessential Interventions – Rationales

• Prepare the client for catheterization The client is able to void independently (50 mL at 0830), so catheterization is not currently necessary unless urinary retention develops or continuous bladder monitoring is required later.
• Perform a Nitrazine test This test has already been performed and confirmed rupture of membranes. Repeating it is not essential unless there is uncertainty or new symptoms arise.

❌ Contraindicated Intervention – Rationale

• Ensure the client maintains a supine position while in bed Supine positioning can compress the inferior vena cava, reducing placental perfusion and causing maternal hypotension. Left lateral or upright positions are preferred to optimize uteroplacental blood flow.

? Take-home points

• Rupture of membranes increases the risk of infection, making temperature monitoring and fetal surveillance critical.
• Supine positioning should be avoided in labor due to the risk of supine hypotensive syndrome and compromised fetal oxygenation.
• Ambulation is beneficial in early labor unless contraindicated by maternal or fetal conditions.
• Nitrazine testing is a one-time diagnostic tool for confirming membrane rupture and should not be repeated unnecessarily.

Choice A rationale

Multiple gestation, such as twins or triplets, typically results in elevated maternal serum alpha-fetoprotein (MSAFP) levels because there are multiple fetuses producing AFP. AFP is a protein produced by the fetal liver and yolk sac.

Choice B rationale

Neural tube defects, such as spina bifida or anencephaly, are associated with *elevated* levels of MSAFP due to the open defect allowing leakage of AFP into the amniotic fluid and then into the maternal circulation.

Choice C rationale

Intrauterine growth restriction (IUGR) can sometimes be associated with either normal or slightly elevated MSAFP levels, depending on the underlying cause, but it is not typically linked to *low* levels.

Choice D rationale

Low levels of maternal serum alpha-fetoprotein are associated with an increased risk of Down syndrome (Trisomy 21). This is thought to be due to altered placental function or fetal production of AFP in these pregnancies.