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Applying a fetal scalp electrode directly measures the fetal heart rate (FHR) but is an invasive action and not the initial priority for addressing late decelerations. Late decelerations, often caused by uteroplacental insufficiency, necessitate immediate interventions to improve fetal oxygenation and perfusion before considering invasive monitoring. FHR baseline and variability are already visible on the external monitor, guiding initial management.

Increasing the rate of intravenous fluids, typically a non-oxytocin isotonic solution like lactated Ringer's, aims to increase maternal intravascular volume. This action may improve uterine perfusion and, subsequently, fetal oxygenation. While crucial, it often follows or is implemented concurrently with positioning changes to maximally improve blood flow dynamics.

Administering high-flow supplemental oxygen (10 L/min via nonrebreather) to the mother increases the maternal PO_2, thereby increasing the oxygen concentration gradient and improving oxygen transfer across the placenta to the fetus. This is a critical step in intrauterine resuscitation, yet position change is often the first, easiest, and quickest intervention.

Flexing the knee while resting, especially in a position that causes pressure behind the knee, could potentially increase venous stasis or cause external trauma to a suspected deep vein thrombosis (DVT). The recommended immediate intervention for a suspected DVT is strict bed rest until diagnostic confirmation and initiation of anticoagulation to prevent PE and minimize local trauma.

Massaging the affected limb is strictly contraindicated for a suspected deep vein thrombosis (DVT). The mechanical manipulation caused by massage could potentially dislodge a thrombus from the calf vein, allowing it to embolize to the pulmonary vasculature and cause a life-threatening pulmonary embolism (PE). Immediate reporting and avoiding manipulation are paramount safety measures.

Applying cold compresses causes local vasoconstriction, which can impede circulation and potentially increase local pain and discomfort in a limb already experiencing impaired venous drainage due to a thrombus. Conversely, applying moist heat is sometimes used for comfort in diagnosed DVT to promote vasodilation, but elevation is a more standard and universally applicable comfort and circulation measure.

This response removes the opportunity for the client to bond with and care for her newborn, which is crucial in the immediate postpartum period. It also infers that the nurse lacks confidence in the client's ability to learn this basic care task, potentially fostering feelings of inadequacy or failure in the new parent. This is a non-therapeutic and dismissive communication block.

Stating that the task is "not difficult" is dismissive of the client's expressed anxiety and fear associated with a new experience. This response minimizes the client's feelings and could inadvertently increase her anxiety and feelings of incompetence, violating the principle of therapeutic communication, which requires validation of the client's feelings.

While attempting to normalize the feeling of discomfort, this response shifts the focus onto the nurse's past experience, rather than addressing the client's immediate needs and feelings. A supportive and therapeutic response should focus entirely on validating the client's current feelings and offering direct, practical support and education.

This response does not promote the client's independence or competence in caring for her newborn. Postpartum care emphasizes maternal-infant bonding and self-efficacy, which are essential for a smooth transition to parenthood. By offering to feed the baby instead of assisting the mother, the nurse delays the mother's opportunity to practice a vital parenting skill, potentially increasing anxiety about future caregiving tasks.

While intended to be encouraging, this statement minimizes the client's expressed feelings of apprehension, which is a common experience for new mothers in the postpartum period as they assume new roles. Therapeutic communication requires validating the client's feelings and providing support, rather than dismissively suggesting the task is easy. New parents often need practical, hands-on guidance.

This response focuses on the nurse's personal feelings, shifting the focus away from the client's immediate needs and feelings. Although sharing experiences can sometimes be helpful, the priority is to address the client's current anxiety and provide direct, practical assistance and reassurance, establishing a supportive and non-judgmental environment for learning.

Terbutaline is a beta-2 adrenergic agonist primarily used as a tocolytic to suppress premature labor by relaxing the uterine smooth muscle. A common side effect of beta-agonists is maternal and fetal tachycardia, due to systemic absorption and action on beta-1 receptors. Therefore, a fetal heart rate of 100/min (normal range 110-160/min) indicates fetal bradycardia, an unexpected and concerning finding that necessitates further assessment.

Terbutaline does not directly enhance the production of fetal lung surfactant. Glucocorticoids, such as betamethasone or dexamethasone, are administered to the mother to stimulate fetal lung maturation and increase surfactant production when preterm birth is anticipated, typically between 24 and 34 weeks of gestation. Terbutaline's role is purely to delay labor, not to stimulate fetal lung development.

Beta-2 agonists, like terbutaline, can stimulate glycogenolysis in the liver and muscle, leading to an increase in blood glucose levels (a common maternal side effect). Therefore, the nurse should expect maternal hyperglycemia, not a blood glucose of 63 mg/dL (normal fasting range typically 70-99 mg/dL), which represents hypoglycemia and is an unexpected finding.

Weakness of the lower extremities is a common side effect of epidural analgesia due to the temporary blockade of motor nerve fibers, often managed by cautious ambulation or bed rest. While a concern for client safety, it is generally not immediately life-threatening compared to severe cardiovascular or respiratory issues. The nurse should monitor and ensure safety but this is not the highest priority.

A temperature of 38.2°C (100.8°F) is a low-grade fever, which can be related to the labor process itself, epidural analgesia, or an infection. While requiring monitoring and further assessment, this finding does not represent the immediate, life-threatening instability to the mother or fetus that severe hypotension does. The normal range for oral temperature is around 36.5°C to 37.5°C (97.7°F to 99.5°F).

Pruritus (itching) is a frequent and bothersome side effect of epidural opioids due to the cephalad spread and central effect on the nucleus of the solitary tract. While distressing to the client, it is a non-life-threatening side effect typically managed with antihistamines or low-dose opioid antagonists. It is not the priority compared to the immediate threat of hypoperfusion caused by severe hypotension.

An emergency cesarean birth is indicated for acute obstetric complications or fetal distress. While magnesium toxicity is a severe complication, discontinuing the drug and administering the antidote (calcium gluconate) addresses the immediate maternal instability first. Preparing for an emergency birth is not the initial, corrective action for this specific drug toxicity and associated respiratory depression.

Assessing maternal blood glucose is unrelated to the immediate, life-threatening signs of magnesium sulfate toxicity (hyporeflexia, respiratory depression). These clinical findings directly reflect an excessive serum magnesium level, which can cause respiratory arrest. The priority is to reverse the drug effects immediately by stopping the infusion and administering the specific antidote, calcium gluconate.

The Trendelenburg position (head-down) is sometimes used for hypotension or umbilical cord prolapse. While the client with preeclampsia may have fluid shifts, this position does not reverse the central nervous system depression caused by magnesium toxicity. In fact, it could potentially compromise breathing further by placing abdominal contents against the diaphragm, making it an inappropriate and ineffective intervention for respiratory depression.

Preeclampsia involves systemic vasoconstriction and endothelial dysfunction, leading to fluid shifts and capillary leakage. 1+ pitting sacral edema is a common manifestation of the condition, resulting from protein loss (decreased oncotic pressure) and increased capillary permeability, particularly in dependent areas due to gravity. This finding is consistent with the generalized edema often seen in preeclampsia.

Proteinuria, specifically ≥ 300 mg in a 24-hour urine collection or ≥ 1+ on dipstick (here 3+), is a defining diagnostic criterion for preeclampsia. The kidney damage and increased glomerular permeability due to the disease process allow large plasma proteins, primarily albumin, to leak into the urine. Therefore, this finding is consistent with the diagnosis.

Hypertension, defined as a systolic blood pressure ≥ 140 mm Hg or diastolic ≥ 90 mm Hg (on two occasions, 4 hours apart), is the hallmark of preeclampsia. A blood pressure of 148/98 mm Hg falls within the range required for diagnosis, reflecting the pathologic vasoconstriction characteristic of the disorder. This finding is, therefore, consistent with preeclampsia.

Elevating all four side rails for an adult who is alert and oriented is considered a physical restraint, which is generally prohibited unless medically necessary or an appropriate less restrictive alternative is not feasible. The use of all four side rails is appropriate only for clients requiring seizure precautions or under general anesthesia. Maintaining the safety of the client in labor is crucial, but alternative methods, such as keeping the bed low and call light within reach, should be prioritized.

During active labor, the standard of care for a low-risk client requires intermittent fetal heart rate (FHR) monitoring every 15 to 30 minutes, not every hour. This increased frequency is necessary because uterine contractions and subsequent uteroplacental perfusion changes significantly increase the risk of fetal hypoxemia or acidosis, demanding timely intervention if a non-reassuring FHR pattern develops.

Routine insertion of an indwelling urinary catheter is not indicated in active labor. Catheterization is typically reserved for specific situations, such as epidural anesthesia administration, prolonged labor with inability to void, or postpartum hemorrhage management. Bladder distention can impede fetal descent and cause uterine atony, so the nurse should encourage voiding every two hours, often using straight catheterization if needed.