Ricci, Kyle & Carman: Maternity and Pediatric Nursing, Second Edition Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations; prepU

A nursing instructor is teaching students about preexisting illnesses and how they can complicate a pregnancy. The instructor recognizes a need for further education when one of the students makes which statement?

"A pregnant woman does not have to worry about contracting new illnesses during pregnancy." When a woman enters a pregnancy with a chronic illness, it can put both her and the fetus at risk. She needs to be cautious about developing a new illness during her pregnancy as well as having an accident during the pregnancy.

When developing a plan of care for a pregnant woman who is HIV-positive and in labor, the nurse recognizes that which measure is essential?

using standard precautions For the pregnant woman who is HIV-positive, nurses must always use standard precautions to reduce the risk of HIV transmission. Educating the woman about family planning methods is not as important as adhering to standard precautions. The decision about the mode of birth is based on the woman's viral load, duration of ruptured membranes, progress of labor, and other clinical factors. Breastfeeding is contraindicated, so helping her choose a feeding method would be inappropriate.

A nurse is talking to a newly pregnant woman who had a mitral valve replacement in the past. Which statement by the client reveals an understanding about the preexisting condition?

"I understand that my fetus and I both are at risk for complications." When a woman enters pregnancy with a preexisting condition, both she and her fetus can be at risk of developing complications.

A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus infection in the client who is at:

36 weeks' gestation. According to the CDC guidelines, all pregnant women should be screened for group B streptococcus infection at 35 to 37 weeks' gestation.

A pregnant woman with diabetes is having a glycosylated hemoglobin (HbA1C) level drawn. Which result would require the nurse to revise the client's plan of care?

8.5% An HbA1C level of more than 8% indicates poor control and the need for intervention, necessitating a revision in the woman's plan of care.

In planning care for a pregnant adolescent, which of the following would be most age appropriate?

Allow her to weigh herself at clinic visits. Part of learning a sense of identity (the adolescent developmental task) is learning self-care. Participation in prenatal care can strengthen this. Remaining in school helps prepare an adolescent to be able to support a newborn financially.

A client with rheumatoid arthritis (RA) is in week 38 of her pregnancy. Which intervention should the nurse make with this client?

Ask the client to decrease her intake of salicylates. Although women with RA should continue to take their medications during pregnancy to prevent joint damage, large amounts of salicylates have the potential to lead to increased bleeding at birth or prolonged pregnancy. The infant may be born with a bleeding defect and may also experience premature closure of the ductus arteriosus because of the drug's effects. For this reason, a woman is asked to decrease her intake of salicylates approximately 2 weeks before term. A number of women also take low-dose methotrexate, a carcinogen. As a rule, they should stop taking this prepregnancy because of the danger of head and neck defects in the fetus. There is no need for the client to be on bed rest or to perform the Snellen eye test.

A 44-year-old client is experiencing postpartum hemorrhaging soon after the birth of her first child. She is frightened and asks the nurse what could be causing it. Which of the following should the nurse mention to the client?

Because of her age, the client is more likely to experience a uterus not contracting as readily in the postpartum period, which predisposes her to postpartum hemorrhaging

A woman over age 40 is less likely than a younger woman to enter pregnancy with a previously diagnosed condition, such as hypertension, varicosities, or hemorrhoids.

False A woman over age 40 is more likely than a younger woman to enter pregnancy with a previously diagnosed condition, such as hypertension, varicosities, or hemorrhoids.

A woman with class II heart disease is in the third trimester of her pregnancy. She has been taking good care of herself and has had little difficulty, but to be on the safe side the obstetrician has prescribed bed rest for her for the final month. For her own and the baby's safety, in what position should the nurse advise the client to sleep?

Lie in a semirecumbent position. Semirecumbent position is the best position for circulation of the mother and fetus. Laying flat on the back can induce supine hypotensive syndrome and fully recumbent impedes other circulation.

A woman with cardiac disease gave birth to a 7 lb (3.2 kg) baby by cesarean birth. Which intervention should be implemented during the immediate postpartum period?

Rest, use stool softeners, and monitor tolerance of activity. A woman who has a cardiac condition is at increased risk in the postpartum period. She needs frequent assessment and observation for tolerance. She would also be given education to avoid straining activities such as bowel movements and would be encouraged to have stool softeners and increase fluid and fiber. Restricting the client's activity to bed rest could be detrimental to the client, as could be ambulating to the bathroom only. There is no reason to limit the visits with the infant.

A pregnant woman with type 2 diabetes is scheduled for a laboratory test of glycosylated hemoglobin (HbA1C). What does the nurse tell the client is a normal level for this test?

The upper normal level of HbA1C is 6% of total hemoglobin.

A nurse is caring for a pregnant client with heart disease in a labor unit. Which intervention is most important in the first 48 hours postpartum?

assessing for cardiac decompensation The nurse should assess the client with heart disease for cardiac decompensation, which is most common from 28 to 32 weeks of gestation and in the first 48 hours postpartum. Limiting sodium intake, inspecting the extremities for edema, and ensuring that the client consumes a high-fiber diet are interventions during pregnancy not in the first 48 hours postpartum.

When providing nutritional counseling to a pregnant woman with diabetes, the nurse would urge the client to obtain most of her calories from which source?

complex carbohydrates The pregnant woman with diabetes is encouraged to eat three meals a day plus three snacks, with 40% of calories derived from good-quality complex carbohydrates, 35% of calories from protein sources, and 35% of calories from unsaturated fats. The intake of saturated fats should be limited during pregnancy, just as they should be for any person to reduce the risk of heart disease.

A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client?

diet Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Long-acting insulin usually is not needed for blood glucose control in the client with gestational diabetes. Oral hypoglycemic drugs are contraindicated in pregnancy. Glucagon raises blood glucose and is used to treat hypoglycemic reactions.

For which problem would the nurse be alert in a pregnant woman with gestational diabetes?

hydramnios related to glucose/insulin imbalance Hyperglycemia tends to lead to excessive amniotic fluid (hydramnios) because of osmotic pressure fluid shifts.

The nurse explains to a pregnant client that she will need to take iron during her pregnancy after being diagnosed with iron-deficiency anemia. The nurse suggests that absorption of the supplemental iron can be increased by taking it with:

orange juice. Anemia is a condition in which the blood is deficient in red blood cells, from an underlying cause. The woman needs to take iron to manufacture enough red blood cells. Taking an iron supplement will help improve her iron levels, and taking iron with foods containing ascorbic acid, such as orange juice, improve the absorption of iron. Eating meals high in iron, drinking milk, and eating legumes does not improve the absorption of iron.

A 40-year-old woman comes to the clinic reporting having missed her period for two months. A pregnancy test is positive. What is she and her fetus at increased risk for?

placental abnormalities A woman older than 35 years is more likely to conceive a child with chromosomal abnormalities, such as Down syndrome. She is also at higher risk for spontaneous abortion (miscarriage), preeclampsia-eclampsia, gestational diabetes, preterm birth, bleeding and placental abnormalities, and other intrapartum complications.

A client is diagnosed with peripartum cardiomyopathy (PPCM). Which therapy would the nurse expect to administer to the client?

restricted sodium intake The client with peripartum cardiomyopathy should be prescribed restricted sodium intake to control the blood pressure. Monoamine oxidase inhibitors are given to treat depression in pregnancy not peripartum cardiomyopathy. Methadone is a drug given for the treatment of substance abuse during pregnancy. Complimentary therapies like ginger therapy help in the alleviation of hyperemesis gravidarum not peripartum cardiomyopathy.

What is the role of the nurse during the preconception counseling of a pregnant client with chronic hypertension?

stressing the positive benefits of a healthy lifestyle The nurse should stress the positive benefits of a healthy lifestyle during the preconception counseling of a client with chronic hypertension. The client need not avoid dairy products or increase intake of vitamin D supplements. It may not be advisable for a client with chronic hypertension to exercise without consultation.

Which factor would contribute to a high-risk pregnancy?

type 1 diabetes A woman with a history of diabetes has an increased risk for perinatal complications, including hypertension, preeclampsia, and neonatal hypoglycemia. The age of 33 without other risk factors does not increase risk, nor does type O-positive blood or environmental allergens.

A 25-year-old pregnant client comes to the office for the first prenatal visit. During the history, the client tells the nurse she had tuberculosis 5 years ago. What is the nurse's best response?

"You will have to maintain an adequate level of calcium during your pregnancy." A client who had tuberculosis earlier in life must be especially careful to maintain an adequate level of calcium during pregnancy to ensure the calcium tuberculosis pockets in her lungs are not broken down and the disease is not reactivated. The tuberculosis may reoccur if the intra-abdominal pressure (from pushing) breaks the calcified pockets open; if the woman is positive for active tuberculosis she will have to take isoniazid (INH), rifampin (RIF), and ethambutol HCL, and if the woman has a positive reaction, a chest X-ray or a sputum culture is needed to confirm the diagnosis.

An alert, diabetic, pregnant woman in the hospital experiences some shakiness and diaphoresis with a fasting blood sugar of 60 mg/dL when she awakens in the morning. Which action should the nurse take first?

Administer the client's glucose tablets. The client is hypoglycemic when awakening in the morning. The nurse should provide glucose and be prepared to reassess. The nurse should not recheck at this point, since the client is symptomatic. She does not need insulin, and she will have her morning dose adjusted after breakfast.

A client in week 38 of her pregnancy arrives at the emergency room reporting a sharp pain between her umbilicus and the iliac crest in her lower right abdomen that is increasing. She reports having experienced intense nausea and vomiting for the past 3 hours. Given these symptoms, the nurse suspects which of the following conditions?

Appendicitis With appendicitis, the nausea and vomiting is much more intense than with morning sickness and the pain is sharp and localized at McBurney's point (a point halfway between the umbilicus and the iliac crest on the lower right abdomen). With a ruptured ectopic pregnancy, a woman may experience abdominal pain that is either diffuse or sharp, but it is less likely to occur precisely at McBurney's point. The symptoms described do not match those of pulmonary embolism or left-sided heart failure.

The nurse is caring for a pregnant client who indicates that she is fond of meat, works with children, and has a pet cat. Which instructions should the nurse give this client to prevent toxoplasmosis? Select all that apply.

Eat meat cooked to 160° F (71° C). Avoid cleaning the cat's litter box. Avoid outdoor activities such as gardening. To minimize risk of toxoplasmosis, the nurse should instruct the client to eat meat that has been cooked to an internal temperature of 160° F (71° C) throughout and to avoid cleaning the cat's litter box or performing activities such as gardening. Avoiding children with colds is unreasonable when working with children, and contact with children with colds is not a cause of toxoplasmosis. The cat should be kept indoors to prevent it from hunting and eating birds or rodents.

The nurse should encourage a pregnant client who is taking short-acting insulin for her diabetes to avoid eating after self-administering the insulin.

False Caution women with diabetes to eat almost immediately after injecting short-acting insulin to prevent hypoglycemia before mealtimes.

A pregnant client with sickle cell anemia is at an increased risk for having a sickle cell crisis during pregnancy. Aggressive management for a client experiencing a sickle cell crisis with severe pain includes which measure?

I.V. fluids A sickle cell crisis during pregnancy is usually managed by exchange transfusion, oxygen, and I.V. fluids. Antihypertensive drugs usually aren't necessary. Diuretics would not be used unless fluid overload resulted. The client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis.

Which measure is recommended to prevent transmission of HIV to a newborn if the mother has AIDS?

Prepare for cesarean birth. When a client is HIV positive, the method of birth preferred is cesarean. This method has the lowest transmission rate for passage of the HIV infection to the infant. The nurse should educate the woman on the standard of care for birth in an HIV- or AIDS-positive mother. Avoiding scalp electrodes for internal fetal monitoring, admitting the infant to NICU, and performing an amniotomy are not recommended methods for preventing transmission of HIV to a newborn.

A mother and her 17-year-old daughter, who is in her first trimester, arrive for the daughter's first prenatal visit. The daughter will turn 18 in 2 weeks. The mother is visibly upset about her daughter's pregnancy and interrupts her daughter to answer the nurse's questions that were addressed to the daughter. The nurse says that she would like to talk with the daughter alone. The mother objects. Which of the following should the nurse mention to the mother?

The daughter is an emancipated minor and has the right to speak with the nurse confidentially Parents may have difficulty allowing a daughter to make her own health care decisions. Soon, however, she will be caring for an infant, so she needs this practice in independence and responsibility. You may need to remind parents a pregnant adolescent is regarded as an emancipated minor or a mature minor—a person capable of making health care decisions—and so may sign permission for her own care. The protection of confidentiality for adolescents is based on recognition some minors would not seek needed health care for such concerns as sexual activity, pregnancy, HIV, sexually transmitted infections (STIs), substance abuse or mental health if they could not receive it confidentially. The client in this case need not return to the office when she is 18 or obtain permission from her father to speak with the nurse confidentially.

The clinic nurse teaches a pregestational type 1 diabetic client that constant insulin levels are very important in during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use:

an insulin pump. Because a pregnant client will have some periods of relative hyperglycemia and hypoglycemia no matter how carefully she maintains her diet and balances her exercise levels, an effective method to keep serum glucose levels constant is to administer insulin with a continuous pump during pregnancy.

When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation (congestive heart failure), which include:

dyspnea, crackles, and irregular weak pulse. Signs of cardiac decompensation to congestive heart failure include crackles in the lungs from fluid, difficulty breathing, and weak pulse from heart exhaustion. The heart rate would not be regular, and a cough would not be dry. The heart rate would increase rather than decrease.

A pregnant woman diagnosed with cardiac disease 4 years ago is told that her pregnancy is a high-risk pregnancy. The nurse then explains that the danger occurs primarily because of the increase in circulatory volume. The nurse informs the client that the most dangerous time for her is when?

in weeks 28 to 32 The danger of pregnancy in a woman with cardiac disease occurs primarily because of the increase in circulatory volume. The most dangerous time for a woman is in weeks 28 to 32, just after the blood volume peaks.

A nursing instructor is teaching students about anemia during pregnancy. Which type of anemia does the instructor teach students is most prevalent during pregnancy?

iron-deficiency anemia Iron-deficiency anemia is the most common type in pregnancy. Many woman enter pregnancy with a low iron count because of poor diet, heavy menstrual periods, unwise weight-loss programs, or a combination of these.

A nurse is caring for a pregnant adolescent client, who is in her first trimester, during a visit to the maternal child clinic. Which important area should the nurse address during assessment of the client?

knowledge of child development The nurse should address the client's knowledge of child development during assessment of the pregnant adolescent client. The nurse need not address the sexual development of the client or whether sex was consensual. This would not be an opportune time to discuss birth control methods to be used after the pregnancy.

Which change in insulin is most likely to occur in a woman during pregnancy?

less effective than normal Somatotropin released by the placenta makes insulin less effective. This is a safeguard against hypoglycemia.

A pregnant client has tested positive for cytomegalovirus. What can this cause in the newborn?

microcephaly Signs that are likely to be present in the 10 percent of newborns who are symptomatic at birth include microcephaly, seizures, IUGR, hepatosplenomegaly, jaundice, and rash.

The nurse is providing education to women who had diabetes prior to pregnancy. The nurse is discussing pregnancy-related complications from diabetes. Which factor is a potential complication?

polyhydramnios Polyhydramnios is an increase, or excess, in amniotic fluid and is a pregnancy-related complication associated with diabetes in pregnancy. An infant who is small for gestational age is not associated with a mother who had diabetes prior to pregnancy. Other pregnancy-related complications associated with pregestational DM include hypertensive disorders, preterm birth, and shoulder dystocia.

During the assessment of a laboring client, the nurse learns that the client has cardiovascular disease (CVD). Which assessment would be priority for the newborn?

respiratory function The nurse should identify respiratory distress syndrome as a major risk that can be faced by the offspring of a client with cardiovascular disease. While the other assessments are important, they are not priority.

The nurse encourages a woman with gestational diabetes to maintain an active exercise period during pregnancy. Prior to this exercise period, the nurse would advise her to do which action?

Eat a sustaining-carbohydrate snack. Because exercise uses up glucose, women with diabetes should take a sustaining-carbohydrate snack before hard exercise to prevent hypoglycemia.

A client is 33 weeks pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled?

85 mg/dl Recommended fasting blood glucose levels in pregnant clients with diabetes are 60 to 95 mg/dl. A fasting blood glucose level of 45 g/dl is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dl is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dl in a pregnant client indicates hyperglycemia.

Between her regularly scheduled visits, a woman in her first trimester of pregnancy who is taking iron supplements for anemia calls the nurse at her obstetrician's office reporting constipation. She reports that she has never had this problem before and asks for some advice about how to get relief. What is the best advice the nurse can give her?

Continue taking iron supplements but increase fluids and high-fiber foods; exercise more. Constipation is a common side effect of iron supplementation. The diagnosis of anemia indicates a true need for the iron supplementation; she needs to increase fluid and fiber to relieve the constipation associated with the iron preparations. The nurse should not advise this client to stop taking her iron supplements, even for a few days. The nurse should not advise the client to increase her iron supplementation, nor take the supplements on an every other day basis. These supplements are ordered by the primary care provider based on the client's hematologic status.

A woman with cardiac disease is 32 weeks' gestation and alerts the nurse she has been having spells of light-headedness and dizziness every few days. The nurse provides which intervention as an option to the client?

Decrease activity and rest more often. If the client is developing symptoms associated with her heart condition, the first intervention is to monitor activity levels, decrease activity, and treat the symptoms. At 32 weeks' gestation, the suggestion to induce labor is not appropriate, and without knowledge of the type of heart condition one would not recommend increase of fluids or vitamins. Total bed rest may be required if the symptoms do not resolve with decreased activity.

A pregnant woman diagnosed with diabetes should be instructed to perform which action?

Notify the primary care provider if unable to eat because of nausea and vomiting. During pregnancy, the insulin levels change in response to the production of HPL. The client needs to alert her provider if she is not able to eat or hold down appropriate amounts of nutrition. The client is at risk for episodes of hypoglycemia during the first trimester. She should never discontinue insulin therapy without her provider's directions. The increase of carbohydrates needs to be balanced with protein, and smaller meals would result in hypoglycemia rather than hyperglycemia.

A nurse is assessing a client in her seventh month of pregnancy who has an artificial valve prosthesis. The client is taking an oral anticoagulant to prevent the formation of clots at the valve site. Which of the following nursing interventions is most appropriate in this situation?

Observe the client for signs of petechiae and premature separation of the placenta Subclinical bleeding from continuous anticoagulant therapy in the woman has the potential to cause placental dislodgement. Observe a woman who is taking an anticoagulant for signs of petechiae and signs of premature separation of the placenta, therefore, during both pregnancy and labor. The nurse should not urge the client to discontinue the anticoagulant, as this is not within the nurse's scope of practice and, in any case, the client still needs the anticoagulant to prevent clots. Bed rest is prescribed for clients with a thrombus, to prevent it from moving and becoming a pulmonary embolus. Avoiding the use of constrictive knee-high stockings is to prevent thrombus formation.

A nurse caring for a pregnant client suspected substance use during pregnancy. What is the priority nursing intervention for this client?

Obtain a urine specimen for a drug screening. Substance use during pregnancy is associated with preterm labor, abortion, low birth weight, central nervous system and fetal anomalies, and long-term childhood developmental consequences. It is most important to know what the client is taking in order to provide the best care for the client and newborn.

A young woman with scoliosis has just learned that she is pregnant. Several years ago, she had stainless-steel rods surgically implanted on both sides of her vertebrae to strengthen and straighten her spine. However, her pelvis is unaffected by the condition. Which of the following does the nurse anticipate in this woman's pregnancy?

Potential for greater than usual back pain Surgical correction of scoliosis (lateral curvature of the spine) involves implanting stainless-steel rods on both sides of the vertebrae to strengthen and straighten the spine. Such rod implantations do not interfere with pregnancy; a woman may notice more than usual back pain, however, from increased tension on back muscles. If a woman's pelvis is distorted due to scoliosis, a cesarean birth may be scheduled to ensure a safe birth, but this is not required in this scenario. Vaginal birth, if permitted, requires the same management as for any woman. With the improved management of scoliosis, the high maternal and perinatal risks associated with the disorder reported in earlier literature no longer exist.

A young client who has just learned that she is pregnant admits that she is a frequent heroin user. Which of the following interventions would be the most effective for this client?

Refer the client to a methadone maintenance program If possible, an opiate-dependent woman should be enrolled in a methadone maintenance program during pregnancy. Infants of women taking methadone do not escape abstinence symptoms at birth, and some infants appear to have more severe reactions to methadone abstinence than to heroin. Because a woman is being provided an oral drug legally, however, a fetus is at least ensured better nutrition, better prenatal care, and less exposure to pathogens such as hepatitis B and HIV. Because heroin is so strongly addictive, simply recommending that the client reduce her intake of the drug or discontinue her use altogether would likely not be effective. Moreover, recommending that she maintain her current level of use would not be advisable due to the severe complications that such drug use during pregnancy can cause.

A nurse is client teaching with a 28 weeks' gestation woman who has tested positive for gestational diabetes mellitus (GDM). What would be important for the nurse to include in the client teaching?

She is at increased risk for type II diabetes mellitus after her baby is born. The woman who develops GDM is at increased risk for developing type 2 diabetes mellitus after pregnancy.

While the nurse is weighing a pregnant woman at a regularly scheduled OB visit, the client reports vaginal itching, a great deal of foamy yellow-green discharge, and pain during intercourse. She says this is her first pregnancy and she did not know this was what happened. What can the nurse tell her?

This is not normal for pregnancy; the care provider might test her for trichomoniasis. If it is trichomoniasis, she can be treated with an oral dose of metronidazole. She should call immediately if she has any symptoms that do not seem normal to her. Trichomoniasis is caused by a one-celled protozoa. The symptoms include large amounts of foamy, yellow-green vaginal discharge. Treatment is with metronidazole, and her partner needs to be treated as well. A yeast infection presents with a cottage-cheese like discharge. Chlamydia often has no symptoms. If the woman does experience symptoms, these may include vaginal discharge, abnormal vaginal bleeding, and abdominal or pelvic pain. Gonorrhea may have symptoms so mild that they go unnoticed in the woman. The woman who contracts gonorrhea may have vaginal bleeding during sexual intercourse, pain, and burning while urinating, and a yellow or bloody vaginal discharge.

A woman with a long history of controlled asthma has just had her first antenatal visit for her fourth child. She is late for a meeting and says she knows what to do. What is the best action the nurse can take?

Acknowledge her need to leave but ask her to demonstrate the use of her inhaler and her peak flow meter before she goes; make any necessary corrections to her technique. Remind her to take her regular medications. Management of asthma during pregnancy is very important; the nurse must document the client has the proper ability to manage her asthma for her health and the health of the fetus. Reminding the client to continue taking her prescribed medication to monitor her peak flow daily is not enough. It is the nurse's responsibility to know that the client knows how to take her medications. Monitoring the baby's kicks in the second and third trimester is an appropriate action. Scheduling a return appointment to discuss asthma management is not appropriate. She could have an asthma attack between the time the nurse sees her and the time of the return appointment. Noting in the chart that the woman was not counseled does not relieve the nurse of her obligation to ensure that the woman knows how to use her inhaler and her peak flow meter.

The nurse is caring for a 2-day-old newborn whose mother was diagnosed with cytomegalovirus during the first trimester. On which health care provider prescription should the nurse place the priority?

Perform a hearing screen test. Symptoms of CMV in the fetus and newborn, known as CMV inclusion disease, include hepatomegaly, thrombocytopenia, IUGR, jaundice, microcephaly, hearing loss, chorioretinitis, and intellectual disability. A hearing screen would be priority over monitoring growth and development because that will have to be done over an extended period of time. Urine and pulse are not important with this diagnosis.

A woman who has sickle cell anemia asks the nurse if her infant will develop sickle cell disease. The nurse would base the answer on which information?

Sickle cell anemia is recessively inherited. Sickle cell anemia is an autosomal recessive disease requiring that the person have two genes for the disease, one from each parent. If one parent has the disease and the other is free of the disease and trait, the chances of the child inheriting the disease is zero. The other options are incorrect as they give misinformation to the client and are inappropriate answers.