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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 .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

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.


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Related Questions

Correct Answer is D

Explanation

A. Maternal vital signs are important for overall assessment, but they do not provide immediate information about fetal descent or imminent birth. The symptoms described are more suggestive of rapid labor progression rather than a maternal systemic issue.

B. Fetal heart rate assessment is essential in labor, but the client’s urge to defecate and nausea strongly suggests fetal descent and cervical dilation. Before focusing on fetal tracing interpretation, the nurse should confirm labor progression to anticipate delivery.

C. Meconium-stained discharge may occur in labor, but assessing discharge does not address the most likely cause of the client’s symptoms. The priority is to determine cervical dilation and fetal station.

D. An urge to bear down, nausea, and rectal pressure during a contraction are classic signs of advanced labor and fetal descent. A vaginal examination is the priority to assess cervical dilation and prevent inadvertent delivery without preparation.

Correct Answer is C

Explanation

Choice A rationale

The critical congenital heart disease (CCHD) screening is typically performed when the newborn is between 24 and 48 hours of age, or just prior to discharge if that occurs earlier. Performing the test too early, such as between 6 and 12 hours, might yield false negative results due to the persistence of transitional circulation.

Choice B rationale

The results of the CCHD screening are typically available immediately, or within a few minutes, as it involves pulse oximetry readings. There is no waiting period of 1 to 2 weeks for the results, allowing for prompt identification and management of potential cardiac defects, preventing delays in care.

Choice C rationale

The CCHD screening specifically compares the oxygen saturation in the newborn's right hand (pre-ductal) and either foot (post-ductal). A significant difference between these two readings can indicate a shunt or obstruction within the heart or great vessels, suggesting a potential critical congenital heart defect.

Choice D rationale

Collecting a blood sample from the newborn's heel is the procedure for the newborn metabolic screening, which screens for various genetic and metabolic disorders, not the critical congenital heart disease screening. The CCHD screening is a non-invasive test performed using pulse oximetry.

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