A nurse is caring for a client.

Click to highlight the findings that are contraindications to the use of a combined oral contraceptive. To deselect a finding, click on the finding again.

History and Physical

1 year ago:

33-year-old client here for routine physical examination and is requesting contraception until they attempt to conceive in about a year. Client has diabetes mellitus, diagnosed 24 years ago. Care is managed by an endocrinologist, has an insulin pump. States HbA1c was 6.7% last month. Client also has migraine headaches with aura and gastroesophageal reflux disease.

Client is a lifetime nonsmoker, reports rarely drinking alcohol. Client is a law enforcement officer and works full time. Reports exercising three or four times per week, usually walking for 2 to 3 miles or riding a stationary bike. Client had a tonsillectomy at 6 years of age. Also had a deep vein thrombosis while travelling internationally 5 years ago.

Rationale:

• Encourage the client to turn from side to side: Epidural anesthesia can cause hypotension and decreased uteroplacental perfusion due to sympathetic blockade. Frequent position changes help promote venous return, enhance circulation, and optimize fetal oxygenation during active labor.

• Assist the client with ambulation: Epidural anesthesia causes motor and sensory block in the lower extremities. The client will likely have reduced strength and sensation in her legs, making walking extremely dangerous due to the high risk of falls.

• Assess for urinary retention: Epidural anesthesia reduces bladder sensation and the urge to void, increasing the risk of urinary retention. A distended bladder can interfere with fetal descent and labor progress, making ongoing assessment necessary.

• Inform the client to expect drowsiness: Epidurals are local/regional anesthetics, not systemic sedatives. While the client may feel relaxed because the pain has subsided, drowsiness is not an expected side effect of an epidural. If a patient becomes drowsy or lethargic, it could indicate a complication like systemic toxicity or a profound drop in blood pressure.

• Monitor for elevated temperature: Epidural anesthesia is associated with an increased risk of maternal fever. Ongoing temperature monitoring helps identify infection or epidural-related hyperthermia early to protect both the client and fetus.

Rationale for correct choices

• Intrauterine growth restriction: The client has experienced persistent nausea and vomiting, reduced oral intake, and a 1.8 kg (4 lb) weight loss over 5 weeks. These factors contribute to maternal malnutrition, which can limit fetal growth and development. Early identification of inadequate maternal nutrition is critical to prevent complications such as low birth weight, preterm birth, and impaired fetal organ development.

• Thiamine deficiency: Prolonged vomiting and poor nutritional intake increase the risk of vitamin deficiencies, particularly thiamine (vitamin B1). Thiamine deficiency in pregnancy can lead to Wernicke’s encephalopathy, neurological complications, and exacerbate maternal fatigue. Prompt recognition and supplementation are essential for both maternal and fetal health.

Rationale for incorrect choices

• Hypernatremia: While dehydration may accompany vomiting, severe vomiting usually leads to hyponatremia and hypokalemia (electrolyte loss) along with metabolic alkalosis. Hypernatremia is less likely than other complications in this scenario, as the client’s main concern is inadequate intake rather than excessive sodium loss.

• Amniotic fluid embolism: Amniotic fluid embolism is an acute, rare obstetric emergency that typically occurs during labor or immediately postpartum. The client’s current presentation in the first trimester does not indicate risk for this condition.

• Chorioamnionitis: Chorioamnionitis is an intrauterine infection usually associated with membrane rupture and labor. There is no report of infection, fever, or membrane compromise in this client. It is not an immediate risk at this stage of pregnancy.