Level: Foundational
Difficulty: Easy
Subtopic: Pregnancy complications
NCLEX: A 29-year-old client in labor and delivery is being evaluated for preeclampsia symptoms. Assessment data include…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 29-year-old client in labor and delivery is being evaluated for preeclampsia symptoms. Assessment data include rupture of membranes with green amniotic fluid and foul odor. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that rupture of membranes with green amniotic fluid and foul odor.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that rupture of membranes with green amniotic fluid and foul odor.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that rupture of membranes with green amniotic fluid and foul odor.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.