A nurse in an antepartum unit is caring for a client.

Exhibits

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.

• Fetal heart rate: The FHR is elevated at 165–168/min with minimal variability, which may indicate fetal tachycardia and potential distress. Persistent tachycardia requires evaluation for infection, hypoxia, or maternal fever. Early intervention helps prevent complications.
• Characteristics of the amniotic fluid: The fluid is greenish, suggesting meconium-stained amniotic fluid, which can signal fetal hypoxia or distress. Meconium increases the risk of meconium aspiration syndrome in the newborn. Providers must be alerted for appropriate preparations at delivery.

Rationale for Incorrect Options:

• Client's blood pressure: The BP is 128/84 mm Hg, which is within normal limits, especially considering her history of chronic hypertension. There are no signs of preeclampsia or hypertensive crisis at this time.
• Duration of contraction: Contractions lasting 40–60 seconds are expected during active labor. There is no evidence of uterine tachysystole or abnormal contraction pattern requiring provider notification.
• Maternal pain: The client reports pain as 5/10 and is breathing well through contractions. This pain level is tolerable and expected in labor, so it doesn’t warrant immediate provider notification.

A. Cover appliance cords with throw rugs:This increases the risk of tripping and falling, especially for a client with vision loss. Rugs can bunch up or cause uneven surfaces that are hazardous in the home environment, particularly for older adults.

B. Rearrange furniture to clear walkways:Sudden changes in the environment can be disorienting for clients with visual impairment. They often rely on the familiarity of their surroundings for safe navigation. It's safer to keep the layout consistent rather than make abrupt rearrangements.

C. Visit the client once per month to assess medication usage:Monthly visits are too infrequent for an older adult who may have difficulty managing multiple medications and vision loss. More frequent monitoring is necessary to ensure medication adherence.

D. Use container lids of different shapes to indicate times of administration:Tactile cues such as differently shaped lids help them identify the correct medication by feel, promoting independence and accurate self-administration.