A nurse is caring for an adolescent client who is gravida 1, para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Choice A reason:
Administering oxygen via face mask is a common intervention for late decelerations; however, it is not the first-line action. Oxygen is given to improve fetal oxygenation, but repositioning the mother has a more immediate effect on improving uteroplacental blood flow and, consequently, fetal oxygenation12.

Choice B reason:
Increasing the infusion rate of IV fluid is an intervention used to expand maternal blood volume, which can improve placental perfusion. However, this is not the primary action to be taken when late decelerations are noted, as it may take time for the increased fluid to affect the uteroplacental circulation.

Choice C reason:
Elevating the client’s legs can help increase venous return to the heart, potentially improving uteroplacental circulation. Nonetheless, this is not the most immediate action to take for late decelerations, as it does not directly address the potential compression of the vena cava or aorta.

Choice D reason:
Positioning the client on her side, particularly the left side, is the priority nursing action for late decelerations. This position helps relieve pressure on the inferior vena cava, enhancing maternal cardiac output and increasing blood flow to the placenta, which can quickly improve fetal oxygenation and resolve late decelerations

Choice A reason:
While burping can be a sign that a baby is feeding, it is not a reliable indicator of whether the baby is getting enough breast milk. Burping is a way to release air that babies swallow during feeding, which can help prevent discomfort and gas. However, it does not correlate directly with the amount of milk intake.

Choice B reason:
The number of wet diapers is a direct indicator of a baby's hydration status and, by extension, how much breast milk they are receiving. A newborn who is getting enough milk will typically have 6 to 8 wet diapers per day after the first few days of life. This shows that the baby is well-hydrated and is receiving sufficient milk.

Choice C reason:
Sleep patterns in newborns can vary widely, and sleeping for at least 6 hours between feedings is not typical for a 2-day-old baby. Newborns usually need to feed every 2 to 3 hours, and long stretches of sleep without feeding may indicate that the baby is not getting enough milk and does not have the energy to wake and feed.

Choice D reason:
A wake cycle of 30 to 60 minutes after feeding can be normal for some babies, but it is not a measure of whether they are getting enough milk. The wake cycle can be influenced by many factors, including the baby's overall health, comfort, and environment.