A nurse is reviewing signs of effective breastfeeding with a client who is 5 days postpartum.
Which of the following information should the nurse include in the teaching?

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.

Choice A rationale: The client exhibits signs consistent with severe preeclampsia including blood pressure above 160/110 mm Hg, 3+ to 4+ deep tendon reflexes, and positive clonus, which are neurological indicators of central nervous system irritability. These findings increase the risk for eclamptic seizures. The headache, visual disturbances (“spots”), and epigastric pain further indicate imminent seizure risk from cerebral edema and vasospasm. Early intervention is crucial to prevent progression to eclampsia.

Choice B rationale: Elevated blood pressure combined with preeclampsia significantly raises the risk of abruptio placentae, the premature separation of the placenta from the uterine wall. This occurs because hypertension causes vasospasm and weakening of the placental attachment, increasing placental insufficiency and hemorrhage. The client’s edema and headache indicate vascular endothelial dysfunction, contributing to this risk. Abruptio placentae is a critical obstetric emergency requiring urgent recognition.

Choice C rationale: The client’s symptoms and signs of hypertension, headache, epigastric pain, and elevated blood pressure with edema suggest progression toward HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). Although labs are not provided, the clinical presentation fits the syndrome’s prodromal phase. HELLP syndrome is a severe variant of preeclampsia with hepatic involvement, which can cause multiorgan dysfunction and increased maternal-fetal morbidity if untreated.

Choice D rationale: Polyuria, or excessive urine output, is not typical in preeclampsia or related hypertensive disorders; instead, oliguria (decreased urine output below 30 mL/hr) may occur due to renal impairment. The client’s urine output of 25–55 mL/hr borders low normal, signaling possible kidney hypoperfusion, but polyuria is not a recognized complication here. Polyuria is more associated with diabetes or diuretic therapy, not hypertensive pregnancy disorders.

Choice E rationale: Ketoacidosis is metabolic acidosis due to ketone accumulation from uncontrolled diabetes or starvation. This client has no history or symptoms of diabetes or starvation, and no laboratory evidence of hyperglycemia or acidosis is reported. Ketoacidosis is not a complication linked to preeclampsia or hypertension in pregnancy and is therefore unlikely in this case.

Choice F rationale: Fetal macrosomia is excessive fetal growth usually related to maternal diabetes or obesity. This client has no indications of gestational diabetes or excessive fetal growth; fetal heart rate and contractions are within normal limits, and no mention of abnormal fundal height or ultrasound findings is given. The mild hypertension and edema do not predispose to macrosomia.