A nurse is caring for a client in active labor.

Exhibits

The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.

Rationale for Correct Options:

• Placental abruption: This condition involves the premature detachment of the placenta from the uterine wall, often triggered by hypertensive disorders. The client’s elevated blood pressure (148/94 mm Hg), facial edema, and hyperreflexia point toward preeclampsia, a leading risk factor for placental abruption.
• Hypertension: Hypertension during pregnancy compromises uteroplacental blood flow, potentially causing vascular damage and leading to placental separation. The client’s reading reflects stage 1 hypertension, which, along with other signs, raises concern for placental complications such as abruption.

Rationale for Incorrect Options:

• Spontaneous abortion: Typically occurs before 20 weeks gestation, making it irrelevant for a client at 30 weeks. There are no signs of fetal loss or cervical dilation in this case.
• Placenta previa: Presents with painless vaginal bleeding in the second or third trimester. This client has no vaginal bleeding or placental misplacement.
• Chorioamnionitis: This infection would present with fever, uterine tenderness, and fetal tachycardia. The client is afebrile, has clear lung sounds, and shows no evidence of intrauterine infection.
• Oligohydramnios: Usually detected via ultrasound or significantly low fundal height. The client's fundal measurement (29 cm at 30 weeks) is appropriate, and there’s no mention of decreased amniotic fluid.
• Hyperreflexia: Although suggestive of preeclampsia, it is a secondary symptom that indicates neurologic involvement and seizure risk rather than directly causing placental abruption.
• Vomiting: While it may be associated with preeclampsia, it is non-specific and does not independently increase the risk of placental abruption without supporting findings like hypertension or abdominal pain.

A. Systemic lupus erythematosus: SLE primarily affects connective tissue and organs through inflammation but rarely impacts the neuromuscular coordination needed for swallowing. It does not significantly raise aspiration risk during enteral feeding.
B. Increased gastric motility: Increased gastric motility helps clear stomach contents more quickly, decreasing the chance of regurgitation and aspiration. It is not typically considered a risk factor for aspiration.
C. Parkinson's disease: Parkinson’s disease impairs muscle coordination, including muscles used for swallowing. This dysphagia increases the risk of aspiration, especially with liquid feedings via a nasogastric tube.
D. Celiac disease: Celiac disease affects the small intestine’s ability to absorb nutrients but does not interfere with the swallowing reflex. It does not increase the risk of aspiration with tube feedings.