A nurse is caring for a client who is 12 hours postpartum and has an episiotomy.
Which of the following actions should the nurse take?

Choice A rationale

Group B Streptococcus (GBS) is a bacterium that can colonize the genitourinary and gastrointestinal tracts. Screening for GBS is typically performed between 35 and 37 weeks of gestation, not 36 weeks exactly, using a vaginal and rectal swab culture. This timing allows for identification and treatment with intrapartum antibiotics, such as penicillin or ampicillin, to prevent vertical transmission to the newborn during labor and delivery, which can lead to serious neonatal infections like sepsis, pneumonia, or meningitis.

Choice B rationale

Maternal serum alpha-fetoprotein (MSAFP) screening is a blood test typically performed between 15 and 20 weeks of gestation, with optimal timing around 16 to 18 weeks. It is used to screen for potential chromosomal abnormalities and neural tube defects. Performing this screening at 6 weeks of gestation would be too early, as the levels of alpha-fetoprotein would not be sufficiently elevated or stable enough to provide accurate and reliable diagnostic or screening information for fetal anomalies.

Choice C rationale

Screening for gestational diabetes mellitus (GDM) is generally performed between 24 and 28 weeks of gestation using an oral glucose tolerance test (OGTT). This period allows for the detection of glucose intolerance that develops during pregnancy, often due to increasing insulin resistance caused by placental hormones. Screening at 12 weeks of gestation would be too early, as the physiological changes leading to GDM typically manifest later in pregnancy.

Choice D rationale

While regular urine specimens are important throughout pregnancy to screen for conditions like urinary tract infections (UTIs), pre-eclampsia, and gestational diabetes, the frequency of "every 2 months" for a clean-catch urine specimen is not a standard routine. Typically, a urine specimen is collected at each prenatal visit, which is often more frequent than every 2 months, especially as pregnancy progresses. This allows for ongoing monitoring of various parameters.

Choice A rationale: Increasing the rate of maintenance IV fluids improves maternal intravascular volume and enhances uteroplacental perfusion. Late decelerations are indicative of uteroplacental insufficiency, where fetal oxygenation is compromised during contractions. By increasing fluid volume, the nurse can help optimize cardiac output and improve oxygen delivery to the fetus, potentially reducing the frequency or severity of late decelerations.

Choice B rationale: Assisting the client into a lateral position, preferably left lateral, helps relieve pressure on the inferior vena cava and improves venous return. This position enhances uteroplacental blood flow and oxygen delivery to the fetus. It is a first-line intervention for late decelerations, as it can reduce fetal hypoxia by improving maternal-fetal circulation without requiring pharmacologic measures.

Choice C rationale: Oxygen via nasal cannula at 2 L is insufficient to address fetal distress. When supplemental oxygen is indicated for intrauterine resuscitation, it should be administered via a non-rebreather mask at 10 L/min to maximize maternal oxygenation and fetal oxygen delivery. A nasal cannula at 2 L does not provide the high concentration needed to improve fetal oxygenation during late decelerations.

Choice D rationale: Misoprostol is a prostaglandin used for cervical ripening and labor induction. It is contraindicated in the presence of fetal distress, such as late decelerations, because it can cause uterine hyperstimulation and worsen fetal hypoxia. Administering misoprostol in this context could exacerbate the situation and increase the risk of adverse outcomes for the fetus.

Choice E rationale: Notifying the primary health care provider is essential when late decelerations are observed, as they indicate potential fetal compromise. Timely communication allows for further evaluation and potential interventions, such as adjusting oxytocin, initiating intrauterine resuscitation, or preparing for operative delivery if the fetal status does not improve. This action ensures collaborative and responsive care.