A nurse is caring for a client in the labor and delivery unit.
Complete the following sentence by using the list of options
The client is at great risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale for correct choices
• chorioamnionitis: The client’s fever, malodorous vaginal discharge, and tachycardia indicate intra-amniotic infection, making chorioamnionitis the strongest risk. Nitrazine-positive discharge with odor further supports infectious etiology rather than labor-only changes. These findings align with hallmark signs of chorioamnionitis in term pregnancy.
• Temperature: A maternal temperature of 38.7° C demonstrates systemic inflammatory response and is a key diagnostic criterion for intra-amniotic infection. Fever combined with localized vaginal changes increases the likelihood of infection within the amniotic cavity. This makes elevated temperature the most appropriate evidence for the selected risk.
Rationale for incorrect choices
• Abruption placenta: Abruption typically presents with painful bleeding, uterine rigidity, or fetal distress, which are absent here. The client’s symptoms instead center on infection indicators rather than placental separation. No hemodynamic instability or abdominal pain consistent with abruption is reported.
• urinary tract infection: Although leukocyte esterase is positive, the client’s primary symptoms—fever, malodorous discharge, nitrazine-positive fluid—point toward reproductive tract infection rather than urinary involvement. The urinalysis lacks nitrites or other strong evidence of a bacterial UTI. These findings are less consistent than those for chorioamnionitis.
• Contraction patterns: Frequent contractions occur in normal labor progression and do not specifically indicate infection. There is no abnormal uterine activity pattern linked to chorioamnionitis risk. Therefore, contraction pattern does not serve as the defining evidence for this condition.
• Fetal heart rate: A normal baseline FHR of 140/min does not signal infection or distress. Fetal tachycardia would be expected if the fetus were affected by maternal infection, but it is not present here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Candidiasis: Candidiasis is a common fungal infection and is not a nationally notifiable disease. Reporting to the CDC is not required for routine cases.
B. Pelvic inflammatory disease: PID is a complication of sexually transmitted infections, but it itself is not a reportable condition. The underlying infection, if it is a notifiable STI, may need to be reported instead.
C. Methicillin-resistant Staphylococcus aureus: MRSA infections acquired in the community or healthcare settings are not universally reportable to the CDC. Reporting requirements vary by state, but MRSA is generally monitored rather than mandatorily reported nationally.
D. Syphilis: Syphilis is a nationally notifiable sexually transmitted infection. Cases must be reported to local and state health departments, which then notify the CDC. This allows for public health tracking, contact tracing, and prevention of further transmission.
Correct Answer is ["B","C","D","G"]
Explanation
A. Group B streptococcus β-hemolytic status: The client is GBS negative, which does not indicate a labor complication. This finding decreases the need for intrapartum antibiotic prophylaxis and does not pose a risk to the fetus or labor progress at this time.
B. Maternal heart rate: The maternal heart rate is 110/min, which is elevated and may indicate early systemic infection, especially when paired with fever. Tachycardia during labor can signal maternal distress or infection and requires prompt assessment to prevent maternal and fetal complications.
C. Contraction pattern: Contractions are occurring every 5 minutes for the past hour but are not described as coordinated or progressing normally. In the presence of infection markers such as fever and tachycardia, this pattern may suggest dysfunctional labor, where infection or inflammation disrupts normal uterine activity.
D. Vaginal discharge: The discharge is described as malodorous and nitrazine-positive, findings that strongly suggest possible chorioamnionitis or another infectious process. Odorous fluid associated with ruptured membranes requires immediate provider notification due to risks of neonatal sepsis.
E. Cervical assessment: The client is now 3 cm dilated, which is appropriate for early labor in a primigravida and does not indicate a complication. This finding aligns with expected cervical changes leading toward active labor.
F. Pain rating: A pain score of 4 at rest and 8 during contractions is typical for early labor and does not represent a complication. Pain naturally increases as contractions strengthen and the cervix dilates, reflecting normal physiologic progression.
G. Temperature: A temperature of 38.7°C (101.7°F) indicates maternal fever, a significant concern during labor. Fever in combination with tachycardia and abnormal discharge suggests intra-amniotic infection, which can rapidly progress and threaten both maternal and fetal well-being.
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