A nurse is caring for a female client, age 32, at 28 weeks of gestation, admitted to the antepartum unit with a diagnosis of HELLP syndrome.

The nurse is assessing the client 15 minutes later. For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client’s condition is improving, or an indication that the client’s condition is worsening.

Fetal hypoxia occurs when oxygen delivery to the fetus is compromised. In this client, the contraction pattern of very frequent, prolonged contractions every 1–2 minutes lasting 90–120 seconds results in uterine tachysystole, which reduces uteroplacental blood flow during contractions. Normal contraction frequency is no more than 5 contractions in 10 minutes. Excessive contractions increase uterine tone, decrease relaxation time, and limit oxygen exchange, causing fetal heart rate changes like late decelerations and minimal variability. This leads to fetal hypoxia, a critical risk in labor complicated by these contraction abnormalities.

Rationale for incorrect Response 1 options:
Abruptio placentae is a sudden placental separation causing bleeding and pain, which is not directly indicated here, as there is no vaginal bleeding or sharp pain described.
Uterine tachysystole describes the contraction pattern itself rather than a complication; it is a cause, not the adverse outcome.
Chorioamnionitis is infection of fetal membranes, usually indicated by fever and uterine tenderness, neither present here.

Rationale for incorrect Response 2 options:
Gestational hypertension contributes to fetal risk but is not the immediate cause of the current fetal distress.
Fetal heart rate variability describes fetal condition but does not cause fetal hypoxia; rather, it signals it.
Intrauterine growth restriction indicates chronic fetal compromise but is not the direct cause of acute fetal hypoxia during labor contractions.

Take home points:

• Uterine tachysystole causes reduced oxygen delivery by limiting uterine relaxation time, risking fetal hypoxia.
• Fetal hypoxia manifests as late decelerations and minimal variability on fetal monitoring.
• Abruptio placentae and chorioamnionitis have distinct clinical signs, which differ from those caused by contraction abnormalities.
• Differentiating causes of fetal distress is vital for timely intervention during labor to prevent adverse outcomes.

The nurse should further evaluate respiratory characteristics and muscle tone to determine if the newborn is experiencing a complication.

Rationale for correct answers
Respiratory characteristics are critical to assess because irregular and shallow breathing in a newborn can indicate neurological or respiratory dysfunction. Normal neonatal respiratory rate ranges from 30 to 60 breaths per minute with regular pattern; deviations may signal distress or central nervous system issues. Muscle tone evaluation is essential since increased tone with tremors suggests possible neurologic irritability or withdrawal. Normal newborn muscle tone should be moderate, neither hypotonic nor hypertonic, with symmetrical movement. These signs correlate with the high-pitched cry, tremors, and exaggerated reflexes noted, which may indicate neurological complications such as withdrawal syndrome or hypoxic-ischemic encephalopathy.

Rationale for incorrect answers
Heart rate (A) is important but was not reported abnormal; normal neonatal heart rate ranges from 120 to 160 beats per minute and the absence of murmurs suggests no cardiac compromise. Temperature (C) is less urgent as mucous membranes are moist and skin warm and dry, indicating stable thermoregulation; normal newborn temperature is 36.5–37.5°C. Feeding patterns (D) appear adequate with no difficulty reported, making this less immediately concerning.

Rationale for incorrect answers
Moro reflex (A) and Babinski reflex (B) are both present and exaggerated, which may be reactive but less specific for immediate concern than muscle tone abnormalities. Skin color (D) is normal without cyanosis or jaundice, reducing the likelihood of hypoxia or hemolytic issues.

Take home points

• Respiratory pattern irregularities in newborns may indicate neurological or respiratory dysfunction.
• Abnormal muscle tone and tremors are key signs of potential neurological complications.
• Normal heart rate, temperature, feeding, and skin color reduce likelihood of cardiac or systemic illness.
• Reflex exaggeration alone is less specific than muscle tone and respiratory changes for early complication detection.