A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor.
What should be the nurse’s priority action?

Choice A rationale
A patient at 28 weeks of gestation receiving terbutaline may report fine tremors. This is a common side effect of terbutaline, which is a medication used to relax the muscles in the uterus to prevent premature labor. However, while it may be uncomfortable for the patient, it is not typically a cause for immediate concern.
Choice B rationale
A tearful patient at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing Braxton Hicks contractions, which are often referred to as “false labor.”. These contractions are usually irregular and do not increase in intensity or frequency. While they can be uncomfortable, they are a normal part of pregnancy and do not typically require immediate medical attention. Choice C rationale
A patient diagnosed with preeclampsia reporting epigastric pain and an unresolved headache should be reported to the healthcare provider immediately. These symptoms could indicate severe preeclampsia, which can lead to serious complications if not treated promptly. Epigastric pain may suggest liver involvement, and a persistent headache could be a sign of neurological involvement, both of which require immediate medical attention.
Choice D rationale
A patient diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes is expected. Proteinuria is a common symptom of preeclampsia, and hyperreflexia can be a sign of increased neurological excitability, a common feature of preeclampsia. However, these findings alone do not typically require immediate medical attention.

Choice A rationale
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a newborn. Macrosomic newborns, or those with a high birth weight, may have increased fat deposits, but this is not the primary cause of respiratory distress.
Choice B rationale
A brachial plexus injury is a type of birth injury that can occur due to difficulties during delivery, such as a prolonged labor or a breech presentation. It involves damage to the bundle of nerves that supply the arms and hands. However, it does not directly cause respiratory distress syndrome.
Choice C rationale
Increased blood viscosity could potentially contribute to respiratory distress, but it is not the most likely cause in a macrosomic newborn whose mother has poorly controlled type 2 diabetes. High blood sugar levels in the mother can lead to high insulin levels in the newborn, which is a more direct cause of respiratory distress.
Choice D rationale
Hyperinsulinemia, or high levels of insulin in the blood, is the most likely cause of respiratory distress in this case. When a mother has poorly controlled diabetes, the baby’s pancreas may respond to high glucose levels by producing extra insulin. After birth, the baby may have hypoglycemia (low blood sugar) and increased red blood cell production, both of which can contribute to respiratory distress.