A nurse is caring for a client who reports a recent episode of painful sores on the perineum, muscle aches, and chills for about 2 weeks.
The client currently denies pain but reports sitting is uncomfortable at times.
The client denies dysuria and reports mild vaginal itching.
What should the nurse anticipate?

Choice A rationale

The maternal serum alpha-fetoprotein test is a part of what’s often called the “triple screen” that can assess whether a pregnant woman may be at increased risk of carrying a baby with certain disorders, such as neural tube defects (spinal defects) or Down syndrome.

Choice B rationale

While the test can provide information about the risk of certain birth defects, it does not assess various markers of fetal well-being.

Choice C rationale

The test does not identify an Rh incompatibility between the mother and fetus. That would be determined through separate blood tests.

Choice D rationale

The test does not assess fetal lung maturity. Other tests, such as amniocentesis, can provide this information.

Choice A rationale

While determining the viability of the fetus is an important aspect of prenatal care, it is not the primary purpose of an ultrasound in this scenario. The client’s report of feeling the baby moving suggests that the fetus is likely viable.

Choice B rationale

The primary purpose of the ultrasound in this scenario is to locate the placenta. Heavy, red vaginal bleeding at 38 weeks of gestation could indicate a complication such as placenta previa, where the placenta covers the cervix. An ultrasound can help confirm this diagnosis.

Choice C rationale

Measuring the biparietal diameter is a method used to estimate fetal weight and gestational age. However, in this scenario, the client is already known to be at 38 weeks of gestation, and the sudden onset of heavy, red vaginal bleeding is a more immediate concern.

Choice D rationale

Assessing fetal lung maturity is typically done when there is a risk of preterm delivery. In this scenario, the client is already at 38 weeks of gestation, which is considered full term. The immediate concern is the heavy, red vaginal bleeding.