A nurse is caring for a 32-year-old female client in the postpartum unit who had a cesarean birth due to preeclampsia. The client has been prescribed misoprostol.

Exhibits

The nurse is assessing the client 1 hour later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.

The correct answer is choiced. Exert upward pressure on the presenting part.

Choice A rationale:

Administering a tocolytic medication can help reduce uterine contractions, but it is not the immediate priority in this emergency situation. The primary goal is to relieve pressure on the umbilical cord to restore blood flow to the fetus.

Choice B rationale:

Wrapping the cord in a sterile towel moistened with warm sterile normal saline is important to prevent the cord from drying out and to maintain its temperature. However, this action does not address the immediate need to relieve pressure on the cord.

Choice C rationale:

Applying oxygen via facemask to the client can help improve maternal oxygenation, which indirectly benefits the fetus. However, it does not directly address the immediate issue of relieving pressure on the umbilical cord.

Choice D rationale:

Exerting upward pressure on the presenting part is the most critical action to take first.This maneuver helps to relieve pressure on the umbilical cord, thereby restoring blood flow and oxygen to the fetus, which is essential in this emergency situation.

Choice A rationale
Maternal cytomegalovirus (CMV) infection is a serious health concern as it is associated with severe birth defects like sensori-neural hearing loss, impairment of cognitive development, and cerebral palsy. It is acquired by contact with body fluids and by vertical transmission from mother to fetus. Transmission can occur via the saliva and urine of the newborn, which is why this is the correct answer.
Choice B rationale
CMV does not require airborne precautions. It is not an airborne disease; it is spread through close, direct contact with a person infected with the virus.
Choice C rationale
CMV does not cause visible lesions on the mother’s genitalia. This is a characteristic of other sexually transmitted infections, not CMV2.
Choice D rationale
Mothers do not receive prophylactic treatment with acyclovir prior to delivery to prevent CMV2. Acyclovir is an antiviral medication used to treat herpes simplex virus infections, not CMV2.