A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?

Choice A rationale:

Assessing for bladder distention is important for postpartum clients, especially those who have undergone perineal trauma during childbirth. However, it is not the priority assessment during a sitz bath. The sitz bath is usually done to promote healing and comfort, and monitoring pulse rate takes precedence to identify any adverse reactions.

Choice B rationale:

Pulse rate should be the priority assessment during a sitz bath for a postpartum client. Sitz baths can cause vasodilation, leading to a potential drop in blood pressure, increased heart rate, or dizziness. Monitoring the pulse rate helps identify any cardiovascular changes or adverse reactions.

Choice C rationale:

Respiratory rate is not the priority assessment during a sitz bath. It is essential to monitor, but it is less likely to be affected directly by the sitz bath compared to the pulse rate and cardiovascular changes.

Choice D rationale:

Monitoring the color of lochia is essential for assessing postpartum bleeding and uterine healing. However, during a sitz bath, the priority assessment should be focused on cardiovascular changes and any adverse reactions the client might experience.

Choice A rationale:

Placing the newborn under a radiant heat warmer is used to prevent cold stress. Newborns are at risk of losing body heat rapidly, and cold stress can lead to various complications, including respiratory distress, hypoglycemia, and metabolic acidosis. The radiant heat warmer helps maintain the baby's body temperature within the normal range, promoting overall stability and reducing the risk of cold-related issues.

Choice B rationale:

The nurse should not choose choice B, "Respiratory depression,” as the action used to prevent. Placing the newborn under a radiant heat warmer does not specifically target respiratory depression. Respiratory depression in newborns may be related to various factors, such as anesthesia exposure during delivery or certain medications, and it requires appropriate monitoring and management rather than just heat regulation.

Choice C rationale:

The nurse should not choose choice C, "Thermogenesis,” as the action used to prevent. Thermogenesis refers to the generation of heat in the body, which is essential for maintaining body temperature. While the radiant heat warmer indirectly supports thermogenesis by preventing heat loss, the main purpose of using the warmer is to prevent cold stress, as stated in choice A.

Choice D rationale:

The nurse should not choose choice D, "Tachycardia,” as the action used to prevent. Tachycardia refers to an abnormally fast heart rate, and the use of a radiant heat warmer does not specifically target this condition. The purpose of the warmer, as explained earlier, is to maintain the baby's body temperature and prevent cold stress, not to address tachycardia.