As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that

Correct Answer: A

Rationale: The correct answer is A: immediate birth is required. The positive Kleihauer–Betke test indicates fetal-maternal hemorrhage, where fetal blood enters the maternal circulation. This can lead to fetal-maternal transfusion, causing fetal anemia. Immediate birth is necessary to assess and manage potential fetal distress, such as anemia and hypoxia, due to the trauma from the MVA. Choices B, C, and D are incorrect: B: Transferring to critical care unit is not the immediate priority. The focus should be on addressing the fetal distress. C: RhoGAM is given to Rh-negative mothers to prevent Rh sensitization, but it is not directly related to the positive Kleihauer–Betke test result. D: Tetanus shot administration is important for tetanus prevention, but it is not the priority in this case where immediate birth is required due to fetal-maternal hemorrhage.

Correct Answer: C

Rationale: The correct answer is C: Urine output >100 mL/hour. This signifies improved kidney function, a key indicator of recovery in preeclampsia. Increased urine output indicates better kidney perfusion and reduced risk of complications like renal failure. A: 1+ protein in urine suggests ongoing kidney damage. B: 2+ pitting edema in lower extremities indicates fluid retention, a common symptom of preeclampsia. D: Deep tendon reflexes +2 are not specific to preeclampsia recovery, although hyperreflexia can be seen in severe cases.

Correct Answer: B

Rationale: The correct answer is B: Assess the patient's respiratory rate. A magnesium level of 7.6 mg/dL is above the therapeutic range (4-7 mg/dL) and can lead to magnesium toxicity. Respiratory depression is a common early sign of magnesium toxicity. Assessing the patient's respiratory rate is the priority to monitor for this potentially life-threatening complication. Stopping the infusion of magnesium (Choice A) is not the immediate priority as the patient's respiratory status needs to be assessed first. Assessing deep tendon reflexes (Choice C) is important for magnesium toxicity but not as urgent as assessing respiratory rate. Notifying the health care provider (Choice D) can be done after assessing the patient's respiratory rate.

Correct Answer: C

Rationale: Pregnancy often leads to an improvement in rheumatoid arthritis due to the immunosuppressive state that occurs to prevent rejection of the fetus. This reduction in immune activity can alleviate symptoms of rheumatoid arthritis. On the other hand, epilepsy, Bell's palsy, and SLE do not typically improve during pregnancy and may even worsen due to hormonal changes and stress on the body. Epilepsy can be challenging to manage during pregnancy, as seizures can potentially harm both the mother and the fetus. Bell's palsy may not improve and could be exacerbated by hormonal changes. SLE is a chronic autoimmune disease that can be unpredictable during pregnancy, with potential flares and complications for both the mother and the fetus.

Correct Answer: C

Rationale: The correct answer is C: bacterial endocarditis. Pregnant patients with mitral valve stenosis are at increased risk for developing bacterial endocarditis due to the presence of abnormal valve structures. This condition can lead to serious complications including septic emboli and heart failure. Hypertension (choice A) is not directly related to mitral valve stenosis. Postpartum infection (choice B) is not a primary concern in this scenario. Upper respiratory infections (choice D) are not specifically associated with mitral valve stenosis. In summary, anti-infective prophylaxis is indicated to prevent bacterial endocarditis in pregnant patients with a history of mitral valve stenosis.