A nurse is caring for a female client, age 29, at 39 weeks of gestation in the intrapartum unit following spontaneous rupture of membranes.

Complete the following sentence by using the lists of options.
The client is at risk for developing

_________

as evidenced by

__________

.

• Moderate maternal bleeding: Worsening condition. HELLP syndrome involves platelet consumption and liver dysfunction that can cause coagulopathy and bleeding risk. New or increased bleeding signals disease progression and possible disseminated intravascular coagulation (DIC).
• Client reports ringing in ears: Worsening condition. Tinnitus can be a sign of hypertensive encephalopathy or central nervous system involvement from severe preeclampsia/HELLP, indicating neurological deterioration.
• BP 180/100 mm Hg: Worsening condition. A significant increase from baseline hypertension signals uncontrolled blood pressure and heightened risk for stroke, organ damage, and progression of HELLP.
• Client reports sharp, stabbing abdominal pain: Worsening condition. This could indicate hepatic hematoma or infarction, a serious complication of HELLP syndrome due to liver injury.
• FHR 80/min with absent variability: Worsening condition. Fetal bradycardia with absent variability indicates fetal distress, often from placental insufficiency related to maternal vascular compromise.
• PT 12 seconds: Indication of improving condition. Normal prothrombin time (PT range ~11-13.5 seconds) suggests stable coagulation status, indicating no worsening coagulopathy or bleeding tendency at this moment.

The client is at risk for developing Intraamniotic infection as evidenced by White blood cell count.

Rationale for correct answers:
Intraamniotic infection (chorioamnionitis) is a bacterial infection of the amniotic sac often associated with prolonged rupture of membranes and labor. This client has spontaneous rupture of membranes (SROM) 1 hour ago with positive nitrazine test confirming amniotic fluid presence. The elevated white blood cell count (19,800/mm³; normal 5,000–15,000/mm³) is an early marker of infection or inflammation. The presence of group B streptococcus further increases infection risk. The amniotic fluid is moderate and clear, which is normal, so fluid characteristics alone do not indicate infection. Early identification and management of intraamniotic infection are critical to prevent maternal and fetal morbidity.

Rationale for incorrect Response 1 options:
Fetal hypoxia typically manifests as abnormal fetal heart rate patterns such as late decelerations or decreased variability, which are not present here (FHR 150/min, moderate variability). Labor dystocia refers to abnormal or slow labor progress; with 2 cm dilation and regular contractions, no evidence suggests dystocia yet. Gestational hypertension is a maternal hypertensive disorder unrelated to current rupture or WBC findings.

Rationale for incorrect Response 2 options:
Amniotic fluid characteristics (clear, moderate) are normal and not indicative of infection. Uterine tone is moderate and normal on palpation, not suggesting infection or abnormal labor. Cervical exam findings (2 cm dilation, 10% effacement) are early labor signs but do not indicate infection risk.

Take home points:

• Elevated WBC after rupture of membranes signals increased risk of intraamniotic infection.
• Clear amniotic fluid with positive nitrazine confirms membrane rupture but does not confirm infection.
• Early labor signs should be monitored for infection risk, especially with group B strep positive status.
• Differentiating infection from other labor complications like dystocia or fetal hypoxia relies on clinical signs and fetal monitoring.