Share This Link

Apply a fetal scalp electrode: A fetal scalp electrode provides more accurate fetal heart rate monitoring if external monitoring is inadequate. However, it is invasive and not priority when addressing signs of fetal distress like late decelerations, which require immediate intrauterine resuscitation measures.

Increase the rate of the IV infusion: Increasing IV fluids can improve uteroplacental perfusion by correcting maternal hypotension or increasing circulating volume. However, it is not the immediate intervention; repositioning the client often relieves cord compression or improves placental blood flow more quickly.

Administer oxygen at 10 L/min via a nonrebreather mask: Administering oxygen can increase the oxygen available to the fetus, helping to resolve fetal hypoxia. However, it is implemented after or simultaneously with repositioning the client, as the change in position can immediately alleviate compression.

Flex her knee while resting: Flexing the knee can increase venous stasis and potentially dislodge a thrombus if one is present. Encouraging knee flexion in a client with suspected deep vein thrombosis (DVT) is not recommended due to the risk of embolization and worsening symptoms.

Massage the area: Massaging an area suspected of having a deep vein thrombosis (DVT) is strictly contraindicated. Massaging the affected area can dislodge the clot, leading to a pulmonary embolism, which is a life-threatening complication.

Apply cold compresses: Cold compresses are generally not advised for suspected DVT because they can cause vasoconstriction and further reduce blood flow. Warm compresses may be used in some cases for symptom relief, but only under medical supervision.

"I'll feed him today. Maybe tomorrow you can try it. This response discourages maternal involvement in infant care and fosters dependence on the nurse. It denies the mother the opportunity to bond with her baby and build confidence in caring for the newborn during this critical early period.

"Oh, this isn't difficult. You'll be fine doing this." This statement dismisses the client’s concerns and may make her feel misunderstood or inadequate. It lacks empathy and does not offer the emotional support or guidance that new mothers often need while learning to care for their infants.

"You can learn to feed him; I wasn't comfortable the first time I fed a baby either." This response shifts the focus onto the nurse’s experience rather than supporting the client directly. It misses the opportunity to actively guide or assist the mother in the moment, which is more beneficial.

Fetal heart rate 100/min: This fetal heart rate is below the normal range (110–160 bpm) and may indicate fetal bradycardia. Terbutaline typically causes a transient increase in fetal heart rate due to its beta-adrenergic effects, not a decrease. This finding would therefore not be expected.

Enhanced production of fetal lung surfactant: Surfactant production is more directly stimulated by corticosteroids like betamethasone, not terbutaline. While both medications may be used together in preterm labor, terbutaline's role is to delay labor not to enhance fetal lung maturity.

Maternal blood glucose 63 mg/dL: Terbutaline may cause maternal hyperglycemia, not hypoglycemia. It stimulates glycogenolysis and gluconeogenesis, leading to increased blood glucose levels. A glucose level of 63 mg/dL is below normal and not typically associated with terbutaline use.

Prepare for an emergency cesarean birth: While severe maternal complications can lead to an emergency delivery, the current concern is magnesium toxicity, which must be managed immediately to stabilize the mother. Delivery is not indicated at this point unless there are also signs of fetal or maternal compromise unrelated to magnesium.

Assess maternal blood glucose: While blood glucose can be affected by various conditions, it is not directly related to the signs of magnesium overdose. The immediate concern is the client's respiratory status and neurological compromise due to the medication.

Place the client in Trendelenburg position: Trendelenburg positioning is used to manage hypotension or promote venous return but is not appropriate or helpful in managing magnesium toxicity. It does not address the respiratory depression or neuromuscular suppression present in this situation.

1+ pitting sacral edema: Mild edema is common in both normal pregnancy and preeclampsia. While not diagnostic on its own, sacral or dependent edema can occur in preeclamptic clients due to increased capillary permeability and fluid retention.

3+ protein in the urine: Significant proteinuria, such as 3+, is a key diagnostic criterion of preeclampsia and results from renal impairment caused by endothelial dysfunction. This finding is strongly associated with moderate to severe preeclampsia.

Blood pressure 148/98 mm Hg: A systolic pressure ≥140 mm Hg or a diastolic ≥90 mm Hg after 20 weeks gestation is one of the main diagnostic markers for preeclampsia. This blood pressure reading supports the diagnosis and is entirely consistent with the condition.

Keep four side rails up while the client is in bed: Using all four side rails continuously is considered a restraint and is not necessary unless the client is sedated or disoriented. Standard safety precautions include raising only two or three side rails and monitoring for changes in condition.

Monitor the fetal heart rate (FHR) every hour: During active labor, fetal heart rate monitoring should occur at least every 15 to 30 minutes for low-risk clients and more frequently for high-risk clients. Monitoring only once an hour is insufficient.

Insert an indwelling urinary catheter: Routine placement of an indwelling catheter is not recommended in active labor unless medically indicated. Intermittent catheterization or encouraging voiding is preferred to reduce infection risk and promote mobility during labor.

Cut the umbilical cord: Cutting the umbilical cord occurs after the newborn is fully delivered and the cord is clamped. It is not a priority action during rapid labor before delivery is complete.

Apply perineal pressure to the emerging fetal head: Applying controlled perineal pressure can help support the perineum and reduce tearing. However, it must be done carefully and often under guidance. While important, preventing tearing encompasses more than just pressure application.

Promote delivery of the placenta: Delivery of the placenta occurs after the baby is born. At the stage of rapidly progressing labor with imminent birth, managing delivery safely takes precedence over placental delivery.

"I will reduce my stress level.": Reducing stress during pregnancy supports better maternal and fetal outcomes by lowering the risk of complications such as preterm labor and hypertension. Stress management techniques contribute positively to overall prenatal health.

"I will tell my doctor before using home remedies for nausea.": Discussing any home remedies with a healthcare provider helps prevent potential adverse effects or interactions with other medications, ensuring that treatments are safe for both mother and baby.

"I will monitor my weight gain during the remaining months.": Tracking weight gain allows for timely adjustments in diet and activity to maintain a healthy pregnancy, reducing risks like gestational diabetes or fetal growth problems.

Deep tendon reflexes 4+: Hyperactive reflexes can be a sign of preeclampsia or magnesium toxicity if the client received treatment. While concerning and requiring monitoring, this is not as immediately critical as active hemorrhage.

Fundus at level of umbilicus: A firm fundus at the umbilicus is expected about 4 hours postpartum and indicates normal uterine involution. This finding is reassuring and does not require immediate action.

Approximated edges of episiotomy: Well-approximated episiotomy edges indicate proper healing. This is an expected finding and not a priority concern during the immediate postpartum period.