A nurse is caring for a client who is 39 weeks pregnant and in active labor.

The nurse detects the fetal heart tones above the client’s umbilicus at the midline.

Which of the following positions should the nurse suspect the fetus is in?

Choice A rationale
The umbilical cord typically contains two arteries and one vein, not one artery and one vein. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice B rationale
The umbilical cord typically contains two arteries and one vein, not two veins and one artery. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice C rationale
The umbilical cord typically contains two arteries and one vein, not two arteries and two veins. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice D rationale
The umbilical cord typically contains two arteries and one vein. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.

Choice A rationale
The client’s symptoms of headache, dizziness, blurred vision, 3+ edema in lower extremities, deep tendon reflexes (DTRs) 3+ with positive clonus, and a fetal heart rate (FHR) of 140 with minimal variability are indicative of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. It usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious complications for both the mother and baby. To address this condition, the nurse should: Monitor the client’s blood pressure regularly. Administer prescribed medications to control blood pressure and prevent seizures. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly.
Choice B rationale
Chronic hypertension is a possibility, but it does not fully explain the client’s symptoms. While chronic hypertension can cause headaches and dizziness, it does not typically cause 3+ edema in the lower extremities or positive clonus. Furthermore, chronic hypertension would have been present before the pregnancy or diagnosed before the client reached 20 weeks of gestation.
Choice C rationale
While the client’s symptoms of headache, dizziness, and blurred vision could suggest a neurologic issue, the presence of 3+ edema in the lower extremities and positive clonus are more indicative of preeclampsia. Neurologic status would be monitored as part of the care for a client with preeclampsia.
Choice D rationale
Liver function studies would be relevant if there were symptoms or signs suggesting liver involvement such as upper right abdominal pain, nausea or vomiting, or jaundice. However, the client’s symptoms are more indicative of preeclampsia.