A nurse is caring for a client who is at 33 weeks of gestation.

Medical History Gravida 2 Para 1 Preeclampsia
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

Rationale:

A. "When was the last time you ate meat?": This question is not relevant for a client who adheres to a vegan diet, as they do not consume meat.

B. "Have you considered eating shellfish?": This question is not appropriate for a client who follows a vegan diet, as shellfish is not part of a vegan diet.

C. "How much protein do you eat in a day?":

Correct answer. Protein intake is an important consideration for individuals following a vegan diet, as they may need to ensure they are obtaining adequate protein from plant-based sources.

D. "Are you taking a Vitamin C supplement?": While assessing vitamin intake is important, protein intake is particularly relevant for a client following a vegan diet, as certain plant-based protein sources may be lower in certain essential amino acids compared to animal-based protein sources.

Rationale:

A. Administering oxygen via a nonrebreather mask may be indicated for fetal distress, but the priority in this situation is to protect the umbilical cord from compression and minimize fetal compromise.

B. Cover the umbilical cord with a sterile saline-saturated towel is an appropriate action to prevent the cord from drying out and to reduce infection butimmediate focus should be on relieving pressure on the umbilical cord to ensure adequate fetal perfusion.

C. Initiate an infusion of IV fluids for the client can help stabilize maternal hemodynamics, but it does not directly address the umbilical cord compression. Relieving the pressure on the cord is the immediate intervention to prevent fetal hypoxia.

D. Perform a vaginal examination by applying upward pressure on the presenting part is the priority intervention. In cases of umbilical cord prolapse, the nurse must perform a vaginal examination and apply upward manual pressure on the presenting part (usually the fetal head) to lift it off the umbilical cord. This action relieves compression on the cord and restores blood flow and oxygen delivery to the fetus until an emergency delivery can be performed.