A nurse is caring for a client who is pregnant. The nurse is reviewing the client's medical record.

Exhibits

Select 4 findings that indicate a potential prenatal complication

Rationale for Correct Choices:

• Seizures: The client presents with severe preeclampsia, indicated by BP >160/110 mm Hg, 3+ proteinuria, hyperreflexia (patellar reflex 4+), and persistent headache. These are strong predictors of progression to eclampsia, which is marked by seizures.
• Placental Abruption: Severe hypertension increases the risk of placental abruption due to vascular compromise in the uteroplacental circulation. Decreased fetal movement may be an early warning sign of impaired placental perfusion or separation.

Rationale for Incorrect Choices:

• Cervical Insufficiency: This is a painless cervical dilation often leading to second-trimester loss, unrelated to hypertension or proteinuria. The client is in the third trimester with no signs of cervical changes.
• Hypoglycemia: The client has no history of diabetes, glucose intolerance, or related symptoms. Her urine glucose was only trace, and no medications suggest insulin use.
• Heart Failure: No signs of pulmonary congestion, dyspnea, or elevated heart rate are present. Oxygen saturation is normal, and breath sounds are not mentioned as abnormal, making CHF unlikely at this stage.

Rationale:

A. "Begin each feeding using the same breast.": It's recommended to alternate breasts between feedings to ensure both breasts are emptied regularly. This helps maintain milk production and prevents engorgement or blocked ducts.

B. "Supplement breastfeedings with water every 12 hours.": Newborns do not require supplemental water. Breast milk provides all the necessary hydration and nutrients for the infant’s needs, even in hot weather.

C. "Offer your infant the breast when he shows signs of hunger.": Feeding on demand based on hunger cues—such as rooting, sucking motions, or hand-to-mouth activity—supports adequate nutrition, growth, and milk supply.

D. "Limit the time your infant feeds to 10 minutes on each breast.": Feeding should not be time-restricted. Infants should be allowed to feed until they are satisfied, as some may take longer to extract enough milk, especially in the early weeks.