A nurse is caring for a client who is 42 weeks of gestation.

Exhibits

Based on the assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated

The correct answer is B. Place the client in the lateral position.

A. Increasing the rate of maintenance IV infusion may be necessary, but the initial action should be to address potential aortocaval compression. Repositioning the client to the lateral position helps alleviate compression on the vena cava and improves blood flow to the uterus.

B. Placing the client in the lateral position is the correct first action. Changing the client's position, particularly from a supine to a side-lying position, can relieve aortocaval compression and improve uteroplacental perfusion.

C. Elevating the client's legs is not the priority in this situation. Repositioning the client to the lateral position is more important to address potential aortocaval compression.

D. Administering oxygen using a nonrebreather mask may be indicated, but repositioning the client to the lateral position is the first action to address potential aortocaval compression. Oxygen administration can follow if necessary.

Choice A Reason:

"I should have a goal of maintaining my fasting blood glucose between 100 and 120." This statement does not indicate understanding of the teaching. Recommended target for fasting blood glucose levels during pregnancy in women with diabetes is typically lower, often between 60 and 90 mg/dL.

Choice B Reason:

"I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." This statement does not indicate understanding of the teaching . Exercising when blood glucose is already elevated to 250 or greater may not be safe. Exercise is generally recommended to help manage blood glucose levels, but the specific approach and timing should be discussed with the healthcare provider.

Choice C Reason:

"I will continue taking my insulin if I experience nausea and vomiting." This statement reflects an awareness of the importance of continuing insulin administration even if the client is experiencing nausea and vomiting. Consistent insulin management is crucial for maintaining blood glucose levels within the target range during pregnancy.

Choice D Reason:

"I will ensure that my bedtime snack is high in refined sugar." This statement does not indicate understanding of the teaching. Bedtime snacks should focus on providing sustained energy and stabilizing blood glucose levels. A snack high in refined sugar is not recommended as it can lead to fluctuations in blood glucose levels.