A nurse in the labor and delivery unit is caring for a 31-year-old pregnant female client who is at 31 weeks of gestation.

Exhibits

The nurse is contacting the primary health care provider regarding the client's status. Which of the following interventions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

Based on the provided information, here is the completion of the sentence using the options:

The nurse assesses the Non-Stress Test (NST) and documents the results as Non-Reactive. The nurse contacts the provider and reports the NST results. The nurse anticipates an order for a Biophysical Profile.

A Non-Stress Test (NST) is used to monitor the fetal heart rate (FHR) and its response to fetal movements. A reactive NST indicates that there are accelerations in the FHR in response to fetal movements, which is a sign of fetal well-being. A non-reactive NST means that there are no accelerations in the FHR with fetal movements, suggesting that the fetus might not be as active or responding as expected.

In this case, the NST was non-reactive because there were no accelerations in the fetal heart rate. This can be a cause for concern, as it may indicate potential issues with the fetus that need further evaluation. Therefore, the nurse would document the NST as non-reactive and contact the provider for further assessment.

A Biophysical Profile (BPP) is often ordered after a non-reactive NST. The BPP is a more comprehensive test that includes an ultrasound to assess fetal movement, muscle tone, breathing movements, and amniotic fluid volume, in addition to another NST. This helps to provide a clearer picture of the fetus's well-being.

Choice A rationale

Brisk patellar deep tendon reflexes can indicate central nervous system irritability, which might suggest conditions like preeclampsia or eclampsia if accompanied by other symptoms. It's critical to assess and monitor for further complications.

Choice B rationale

A moderate amount of lochia on the perineal pad over 2 hours is normal postpartum bleeding and does not typically indicate an immediate concern if within expected ranges.

Choice C rationale

A fundus at the level of the umbilicus is an expected finding 4 hours postpartum and indicates normal uterine involution. It is not a priority concern at this stage.

Choice D rationale

Approximated edges of an episiotomy indicate that the incision is healing properly without signs of infection or dehiscence. This is a normal and expected finding in the postpartum period.