The labor and delivery nurse caring for a client at 39 weeks gestation notes that the fetal heart tone is heard most loudly and clearly when auscultated in the upper right abdominal quadrant above the umbilicus.
What is the nurse's best interpretation of this finding?

• White blood cell count: Expected—mild leukocytosis is normal postpartum due to physiological stress.
• Blood clot size: Expected—small clots, like a pea-sized clot, are common and not concerning unless excessive bleeding occurs.
• Uterine findings: Expected—firm and midline uterus indicating effective involution.
• Lochia findings: Expected—progressing normally without signs of infection (no foul odor).
• Calf findings: Expected—a single varicose vein without tenderness or swelling is not concerning.
• Blood pressure: Expected—within normal postpartum range.

Choice A rationale

The client at 6 weeks gestation exhibiting severe abdominal pain, hypotension (86/58 mm Hg), and tachycardia (132/min) suggests a potential ruptured ectopic pregnancy or other acute abdominal emergency requiring immediate intervention. Hypotension indicates inadequate tissue perfusion, and tachycardia is a compensatory mechanism to maintain cardiac output. Severe pain further indicates an acute process that necessitates prompt assessment and treatment to prevent further hemodynamic instability and potential life-threatening complications.

Choice B rationale

While a client with an ectopic pregnancy requires monitoring and care, the vital signs reported (blood pressure 128/84 mm Hg, pulse 88/min) are within normal limits. Normal blood pressure ranges are typically systolic 90-120 mm Hg and diastolic 60-80 mm Hg, and a normal pulse rate is generally 60-100 beats per minute. Although emotional distress from the diagnosis is important, the physiological parameters do not indicate an immediate critical threat compared to the client in Choice A.

Choice C rationale

A client at 9 weeks gestation who received methotrexate for an ectopic pregnancy and reports moderate pain and dizziness with stable vital signs (blood pressure 116/80 mm Hg, pulse 86/min) requires assessment for expected side effects of the medication or signs of treatment failure. Methotrexate can cause abdominal pain as it works to dissolve the pregnancy. While monitoring is necessary, the stable vital signs do not suggest an immediate life-threatening emergency compared to the client in Choice A.

Choice D rationale

A client at 8 weeks gestation with moderate vaginal bleeding, minimal abdominal pain, and stable vital signs (blood pressure 118/72 mm Hg, pulse 96/min) may be experiencing a threatened or inevitable miscarriage. While vaginal bleeding in early pregnancy warrants investigation and monitoring, the stable vital signs and minimal pain do not indicate an immediate critical emergency requiring prioritization over the client in Choice A who presents with signs of hemodynamic instability. .