A charge nurse is teaching a group of staff nurses about fetal monitoring during labor.
Which of the following findings should the charge nurse instruct the staff members to report to the provider?

Choice A rationale

Monitoring uterine contractions is important during labor, but in the context of late pregnancy bleeding, the immediate priority is to assess the well-being of both the mother and the fetus. Contractions may or may not be present at this stage.

Choice B rationale

Placing clean disposable pads is a reasonable action to manage bleeding and assess its characteristics. However, it does not address the immediate need to evaluate the maternal and fetal status, which is critical in a bleeding episode during late pregnancy.

Choice C rationale

Assessing fetal heart rate (FHR) is crucial to determine fetal well-being in the presence of bleeding. Maternal vital signs (blood pressure, heart rate, respiration) are equally important to evaluate the mother's hemodynamic stability. Bleeding in late pregnancy can compromise both maternal and fetal oxygenation and perfusion, making this assessment the highest priority. Normal maternal heart rate is typically 60-100 beats per minute, and normal maternal blood pressure is typically 90/60 mmHg to 120/80 mmHg. The normal fetal heart rate range is 110-160 beats per minute.

Choice D rationale

Performing a venipuncture for hemoglobin and hematocrit levels will provide information about the extent of blood loss and the mother's oxygen-carrying capacity. While this is an important assessment, it is not the immediate priority compared to evaluating the fetal heart rate and maternal vital signs, which provide real-time information about their current status. Normal hemoglobin for pregnant women typically ranges from 10.5 to 14 g/dL in the first and third trimesters and slightly lower in the second trimester due to hemodilution. Normal hematocrit for pregnant women typically ranges from 32% to 42%.

Choice A rationale

A pounding headache, visual changes, and epigastric pain in a patient with pregnancy-induced hypertension (PIH), now known as gestational hypertension or preeclampsia, are serious signs indicating worsening disease severity. These symptoms suggest central nervous system irritability (headache, visual changes) and potential liver involvement or severe preeclampsia (epigastric pain), increasing the risk of eclampsia, which is characterized by seizures.

Choice B rationale

Magnesium sulfate is a medication commonly used to prevent seizures in patients with severe preeclampsia. While it can cause side effects such as flushing, warmth, and muscle weakness, it does not typically cause a pounding headache, visual changes, or epigastric pain. These symptoms are indicative of the underlying disease process, not the medication.

Choice C rationale

While hospitalization can induce anxiety in some patients, the specific combination of a pounding headache, visual changes, and epigastric pain in the context of pregnancy-induced hypertension strongly suggests a physiological basis related to the worsening of the hypertensive disorder, rather than solely psychological distress.

Choice D rationale

While epigastric pain can be associated with gastrointestinal issues, in a patient with pregnancy-induced hypertension experiencing a pounding headache and visual changes concurrently, it is more likely related to hepatic involvement or severe preeclampsia. A focused assessment of the gastrointestinal system alone would not adequately address the potential severity of the situation.