A nurse is assisting a client who is in labor to the bathroom when the client reports a sudden gush of fluid.
The nurse observes an umbilical cord protruding from the client's vagina. Which of the following actions should the nurse take first?

Choice A rationale

While vitamin K is important for coagulation and is often supplemented in newborns, increasing maternal intake of vitamin K during breastfeeding is not a primary nutritional recommendation for the mother. The focus for maternal nutrition during lactation is generally on overall caloric and fluid intake, and specific macronutrients and micronutrients that support milk production.

Choice B rationale

While potassium is an essential electrolyte, and maintaining appropriate levels is crucial for overall health, there isn't a specific recommendation to significantly increase potassium intake beyond general dietary guidelines for a breastfeeding mother. The emphasis is typically on adequate fluid and overall balanced nutrition rather than targeted potassium supplementation for lactation.

Choice C rationale

Breastfeeding significantly increases a mother's energy expenditure due to the metabolic demands of milk production. Therefore, maintaining the same caloric intake as during pregnancy would be insufficient to meet these increased energy needs, potentially leading to maternal fatigue and weight loss. An increase of approximately 330-400 additional calories per day is typically recommended.

Choice D rationale

Adequate fluid intake is crucial for successful lactation. Breast milk is approximately 87% water, and the process of milk synthesis requires a substantial fluid volume. Maintaining adequate hydration, guided by thirst, ensures sufficient substrate for milk production and prevents maternal dehydration, which can negatively impact milk supply and overall well-being. .

Choice A rationale

Elevated maternal serum alpha-fetoprotein (MSAFP) levels are highly suggestive of neural tube defects (NTDs) such as spina bifida and anencephaly. Alpha-fetoprotein (AFP) is a glycoprotein produced by the fetal liver and yolk sac. In NTDs, the incomplete closure of the neural tube allows for leakage of AFP into the amniotic fluid and subsequently into the maternal bloodstream, leading to elevated serum levels.

Choice B rationale

Phenylketonuria (PKU) is an autosomal recessive metabolic disorder characterized by a deficiency in the enzyme phenylalanine hydroxylase, leading to an accumulation of phenylalanine. It is typically identified through newborn screening, not through elevated maternal serum alpha-fetoprotein levels. MSAFP screening is not used for the diagnosis or suspicion of PKU.

Choice C rationale

Trisomy 21, also known as Down syndrome, is a chromosomal disorder caused by the presence of an extra copy of chromosome 21. While maternal serum screening for Trisomy 21 typically involves assessing multiple markers, including alpha-fetoprotein, low levels of MSAFP, in conjunction with abnormal levels of other markers like human chorionic gonadotropin (hCG) and unconjugated estriol, are generally indicative of Trisomy 21. Elevated AFP is not characteristic.

Choice D rationale

Hemophilia is a group of hereditary bleeding disorders caused by deficiencies in specific blood clotting factors, most commonly factor VIII (hemophilia A) or factor IX (hemophilia B). These disorders are genetically inherited and are not associated with or detected by elevated maternal serum alpha-fetoprotein levels. MSAFP is a screening tool for fetal structural anomalies, not coagulation disorders.