A nurse is assisting with the admission of a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding.

Incomplete abortion is the initial diagnosis.

Which of the following actions should the nurse contribute to the client’s plan of care?

Rationale for Choice A: Visual disturbances
Preeclampsia: Visual disturbances, such as blurred vision or seeing spots, can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. It typically develops after 20 weeks of gestation and can progress rapidly.
Potential complications: If left untreated, preeclampsia can lead to seizures (eclampsia), stroke, liver and kidney failure, premature birth, and even death of the mother or baby.
Prompt reporting: Early recognition and management of preeclampsia are crucial for preventing adverse outcomes. Therefore, visual disturbances should be reported to the provider immediately to initiate further assessment and potential interventions.

Rationale for Choice B: Fetal heart rate
No indication for reporting: While monitoring fetal heart rate is essential during pregnancy, the promptness of reporting it to the provider depends on specific concerns. In this case, the fetal heart tones are documented as 1, suggesting a normal rate and rhythm. There's no immediate indication for reporting it as a concerning finding.

Rationale for Choice C: Blood pressure
Hypertension: High blood pressure is a key feature of preeclampsia. Although blood pressure readings are not provided in the scenario, the nurse should measure and report them to the provider, as hypertension is a critical finding that could necessitate further evaluation and treatment.

Rationale for Choice D: Deep tendon reflexes
Hyperreflexia: The client's deep tendon reflexes are 3+, which is considered hyperreflexia. Hyperreflexia can be a neurological sign of preeclampsia, indicating increased excitability of the nervous system. It's important to report this finding to the provider for further assessment and monitoring.

Choice A rationale:

A negative test implies a non-reactive NST, meaning the fetal heart rate (FHR) did not demonstrate the expected accelerations in response to fetal movements.

However, the scenario states that fetal movements were noted, and decelerations were observed. Decelerations, even lasting 30 seconds, are not consistent with a negative test.

Choice B rationale:

A positive test is not a standard term used in the context of NST results.

The term "positive" is more often associated with tests that identify a specific condition or abnormality.

NST results are typically classified as reactive or non-reactive, with further interpretation based on the presence or absence of decelerations and other FHR patterns.

Choice C rationale:

A reactive NST is the desired outcome, indicating a healthy fetal response to movement.

It requires two or more FHR accelerations of at least 15 beats per minute for a minimum of 15 seconds, each within a 20- minute period.

Although the decelerations lasting 30 seconds warrant further assessment, they do not negate the presence of the required accelerations, making the test reactive.

Choice D rationale:

"Non-reactive deceleration of rising in the fetal heart rate during a period" is not a standard NST result terminology.

It incorrectly combines elements of non-reactivity (lack of accelerations) with a description of decelerations, which are distinct FHR patterns.