A nurse is caring for a client who is at 14 weeks of gestation. Which of the following statements should the nurse identify as the client being emotionally prepared for pregnancy?

Rationale for Correct Options:

1. Late decelerations on fetal heart rate (FHR) – First Priority

Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. This is the most urgent concern because prolonged fetal distress can lead to hypoxia and acidosis, increasing the risk of complications such as stillbirth or emergency cesarean birth. Nursing Actions: Reposition the client to left lateral position to improve placental perfusion. Administer oxygen at 10 L/min via a non-rebreather mask. Increase IV fluids to improve maternal circulation. Stop oxytocin if it's being used, as it may be causing excessive contractions. Notify the provider immediately for further interventions, such as potential intrauterine resuscitation or emergent delivery.

1. Positive Group B streptococcus (GBS) status – Second Priority

The client tested positive for GBS, a bacterial infection that can be transmitted to the newborn during birth, leading to neonatal sepsis, pneumonia, or meningitis. While this is a significant concern, it is secondary to the immediate fetal distress from late decelerations. Nursing Actions: Administer IV antibiotics (penicillin G or an alternative) as ordered to prevent neonatal infection. Monitor for signs of infection in the newborn after delivery.

Rationale for Incorrect Options:

• Severe back pain rated 10/10 – Pain management is important, but fetal distress takes precedence over maternal discomfort.
• Restlessness and irritability – These could indicate maternal distress or labor progression, but they are not as urgent as fetal oxygenation.
• Increasing contraction intensity and frequency – This is expected as labor progresses but is not immediately life-threatening.
• Fatigue and emotional distress – While support is essential, it is not a priority over fetal well-being or preventing neonatal infection.

A. Clear rhinorrhea. Mild respiratory illnesses, such as a common cold with clear nasal discharge, do not contraindicate varicella vaccination. The immunization can still be administered unless the child has a moderate to severe illness with fever.
B. Medications for a cardiac anomaly. Having a congenital heart defect or taking cardiac medications does not typically contraindicate varicella vaccination. However, children on high-dose immunosuppressive therapy for heart conditions may need further evaluation before receiving live vaccines.
C. Chemotherapy treatments. Chemotherapy suppresses the immune system, increasing the risk of severe complications from live vaccines like varicella. Children undergoing chemotherapy should not receive live-virus vaccines until immune function has sufficiently recovered, as determined by a healthcare provider.
D. Two diarrhea stools in the last day. Mild, self-limiting diarrhea does not contraindicate vaccination. Only children with severe acute gastrointestinal illness should have vaccinations postponed until they recover.