A nurse is reviewing the electronic medical record of a female client, age 31, at 36 weeks of gestation in the antepartum unit.

Complete the following sentence by using the lists of options.
After reviewing the information in the client’s EMR, the nurse determines that the client is at risk for developing

________

as evidenced by

_______

.

Choice A rationale

Providing an opportunity to connect with others who have experienced similar losses offers significant psychosocial support. Sharing experiences can normalize grief, reduce feelings of isolation, and validate emotions. This peer support can facilitate the grieving process by fostering a sense of community and understanding during a challenging time.

Choice B rationale

While some causes of spontaneous abortion can be identified, many remain unknown even after the expulsion of fetal tissue. Genetic anomalies, chromosomal abnormalities, or uterine factors are often implicated, but a definitive cause is not always determined. Providing this information can create unrealistic expectations and potential disappointment for the client.

Choice C rationale

The decision to view fetal remains is highly personal and depends on individual coping mechanisms and cultural beliefs. For some, it can be a crucial part of acknowledging the loss and beginning the grieving process. Advising against it prematurely removes a potential avenue for closure and validation for the client.

Choice D rationale

Validating the client's grief, regardless of the gestational age, is crucial for emotional well-being. Acknowledging that it is "okay to feel some grief now" provides permission for the client to experience their emotions. Grief is a subjective process, and the intensity and duration are not dictated by the length of the pregnancy.

Choice A rationale: Ensuring suction is available is critical because clients with severe preeclampsia or eclampsia are at risk for seizures that can cause airway obstruction from secretions or vomiting. Suction readiness supports immediate airway management during a seizure, preventing aspiration and maintaining oxygenation, essential in protecting maternal and fetal health.

Choice B rationale: Administering 10 L of oxygen via nasal cannula is not appropriate because nasal cannulas typically deliver oxygen up to 6 L/min; higher flows require a different delivery system like a non-rebreather mask. Also, routine high-flow oxygen is not indicated unless hypoxia is present. The client’s oxygen saturation is normal (99%), so supplemental oxygen at this rate is unnecessary and could cause discomfort or drying of mucous membranes.

Choice C rationale: Raising side rails is a safety measure to prevent injury during seizures or sudden movements caused by central nervous system irritability in preeclampsia. Elevated side rails help protect the client from falls or trauma if a seizure occurs, an essential precaution in clients with neurological symptoms such as hyperreflexia and clonus.

Choice D rationale: Placing a padded tongue blade at the bedside prepares for seizure management by preventing tongue biting and airway obstruction. The padded blade reduces the risk of oral trauma during convulsions and maintains airway patency. However, it should be used carefully to avoid airway injury or obstruction and only if a seizure occurs.

Choice E rationale: Dimming lights reduces environmental stimuli that may exacerbate neurological irritability or trigger seizures in preeclampsia/eclampsia. Bright or flashing lights can increase CNS excitation, worsening headache, visual disturbances, or seizure risk. Creating a calm, low-stimulation environment helps stabilize the client’s neurological status.

Choice F rationale: Placing the client in the supine position is contraindicated because it compresses the inferior vena cava, reducing venous return and cardiac output, potentially worsening placental perfusion. The left lateral position is preferred in hypertensive pregnancy to optimize uteroplacental blood flow and maternal hemodynamics, improving fetal oxygenation and maternal comfort.