A nurse is caring for a 9-year-old child at a clinic.

Exhibits

Select the 3 priority actions that the nurse should take.

Rationale:

Obtain consent for cesarean birth: This is anticipated because the client is presenting with uterine contractions, vaginal bleeding, and abdominal pain, which may indicate complications such as placental abruption or abnormal placental attachment, potentially requiring a cesarean birth for the safety of both the mother and fetus.

Provide intermittent fetal heart rate monitoring: This is anticipated as it is essential to monitor fetal well-being, especially with the reported minimal fetal heart rate variability and potential for fetal distress.

Administer oxygen 10 L via face mask: This is anticipated to improve oxygenation, especially if there is a risk of fetal distress or compromised perfusion due to maternal blood loss.

Prepare the client for an amnioinfusion: This is contraindicated in the setting of vaginal bleeding and suspected placental abruption, as amnioinfusion is typically used for conditions such as oligohydramnios, and it could increase the risk of additional complications in this case.

Initiate IV bolus lactated Ringer’s: This is anticipated as the client has signs of hypovolemic shock due to blood loss, and an IV bolus would be necessary to improve fluid volume and blood pressure.

Insert a urinary catheter: This is contraindicated unless clinically necessary, as urinary catheterization may not be indicated in the immediate management of placental issues or bleeding complications without further evaluation, and it could introduce an infection risk.

A: Disconnecting the suction to the OG tube while holding the baby is not advisable, especially if the baby is on suction due to abdominal concerns such as NEC. The OG tube is used to decompress the stomach, and disconnecting it without proper instructions can worsen the condition. Therefore, this statement indicates a lack of understanding.

B: While genetic factors may influence some neonatal conditions, NEC is not a genetic disorder. The statement about passing a gene to the baby and potentially to the next child is not accurate in this context.

C: Necrotizing enterocolitis (NEC) is a severe gastrointestinal emergency commonly seen in preterm neonates, and it can lead to bowel perforation. In cases of extensive bowel damage or perforation, surgical intervention may be required, including the possibility of an ostomy. This is a correct statement that reflects the understanding of the potential treatment plan for the neonate.

D: NEC typically involves the inability to tolerate feedings, and in such cases, feeding is often withheld temporarily. The baby would not need high-calorie formula in this situation; instead, the focus would be on managing NEC, potentially with IV nutrition or parenteral nutrition (TPN), and addressing the need for surgical intervention.