A nurse is caring for a client who is pregnant.

Exhibits

The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

A. Fax the client's name and identifiable information to the rehabilitation facility: Faxing may be insecure and breach confidentiality.

B. Email the client's health information in an unencrypted file: Unencrypted emails are not secure.

C. Discuss the client's response to the transfer with another staff nurse: This is unnecessary and may breach confidentiality.

D. Provide a verbal report of the client's condition to the paramedic performing the transfer: A direct, verbal report ensures that only essential information is shared securely.

Rationale:

Obtain consent for cesarean birth: This is anticipated because the client is presenting with uterine contractions, vaginal bleeding, and abdominal pain, which may indicate complications such as placental abruption or abnormal placental attachment, potentially requiring a cesarean birth for the safety of both the mother and fetus.

Provide intermittent fetal heart rate monitoring: This is anticipated as it is essential to monitor fetal well-being, especially with the reported minimal fetal heart rate variability and potential for fetal distress.

Administer oxygen 10 L via face mask: This is anticipated to improve oxygenation, especially if there is a risk of fetal distress or compromised perfusion due to maternal blood loss.

Prepare the client for an amnioinfusion: This is contraindicated in the setting of vaginal bleeding and suspected placental abruption, as amnioinfusion is typically used for conditions such as oligohydramnios, and it could increase the risk of additional complications in this case.

Initiate IV bolus lactated Ringer’s: This is anticipated as the client has signs of hypovolemic shock due to blood loss, and an IV bolus would be necessary to improve fluid volume and blood pressure.

Insert a urinary catheter: This is contraindicated unless clinically necessary, as urinary catheterization may not be indicated in the immediate management of placental issues or bleeding complications without further evaluation, and it could introduce an infection risk.