A nurse in a long-term care facility is reviewing a client's laboratory results. The client's potassium level is 5.8 mEq/L (3.5 to 5 mEq/L). Which of the following findings should the nurse expect?

Rationale for Correct Options:

1. Late decelerations on fetal heart rate (FHR) – First Priority

Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. This is the most urgent concern because prolonged fetal distress can lead to hypoxia and acidosis, increasing the risk of complications such as stillbirth or emergency cesarean birth. Nursing Actions: Reposition the client to left lateral position to improve placental perfusion. Administer oxygen at 10 L/min via a non-rebreather mask. Increase IV fluids to improve maternal circulation. Stop oxytocin if it's being used, as it may be causing excessive contractions. Notify the provider immediately for further interventions, such as potential intrauterine resuscitation or emergent delivery.

1. Positive Group B streptococcus (GBS) status – Second Priority

The client tested positive for GBS, a bacterial infection that can be transmitted to the newborn during birth, leading to neonatal sepsis, pneumonia, or meningitis. While this is a significant concern, it is secondary to the immediate fetal distress from late decelerations. Nursing Actions: Administer IV antibiotics (penicillin G or an alternative) as ordered to prevent neonatal infection. Monitor for signs of infection in the newborn after delivery.

Rationale for Incorrect Options:

• Severe back pain rated 10/10 – Pain management is important, but fetal distress takes precedence over maternal discomfort.
• Restlessness and irritability – These could indicate maternal distress or labor progression, but they are not as urgent as fetal oxygenation.
• Increasing contraction intensity and frequency – This is expected as labor progresses but is not immediately life-threatening.
• Fatigue and emotional distress – While support is essential, it is not a priority over fetal well-being or preventing neonatal infection.

• WBC count 6,700/mm³ is unchanged from previous readings, remaining within normal limits, indicating no new or worsening infection or inflammatory response.
• Hemoglobin 12 g/dL represents a significant increase from the previous value of 7.8 g/dL, demonstrating successful red blood cell transfusion and improvement in oxygen-carrying capacity.
• Hematocrit 36% is also markedly improved from 24%, further confirming correction of anemia following transfusion.

• Blood pressure 112/74 mm Hg has increased from a low of 76/45 mm Hg, indicating improved circulatory status and perfusion following fluid resuscitation and transfusion.
• Heart rate 95/min is a decrease from previous tachycardic values (121/min), suggesting stabilization of hemodynamics and resolution of compensatory response to anemia and hypotension.
• Oxygen saturation 100% on 2 L/min O₂ via nasal cannula confirms adequate oxygenation, demonstrating improved hemoglobin levels and effective oxygen delivery.

• Respiratory: bilateral breath sounds clear confirms stable respiratory function, showing no complications such as fluid overload or transfusion-related lung injury.