A nurse is caring for a client who is pregnant and is at the end of their first trimester.
The nurse places the Doppler ultrasound in which of the following locations to begin assessing for the fetal heart tones (FHTs)?

Choice A rationale

Repositioning the client to a left lateral position aims to improve uteroplacental perfusion by alleviating compression of the inferior vena cava by the gravid uterus. This enhances venous return to the mother's heart, increasing cardiac output and ultimately improving blood flow and oxygen delivery to the placenta and fetus, which can resolve late decelerations caused by uteroplacental insufficiency.

Choice B rationale

Documenting findings is a crucial nursing responsibility, but it is not the immediate intervention for addressing late decelerations. Scientific principles dictate that physiological stabilization takes precedence over documentation when fetal well-being is compromised. Documentation would follow after initial interventions are implemented to improve the fetal status.

Choice C rationale

Adjusting fetal monitor sensors might be necessary if the tracing is poor quality, but it does not directly address the physiological cause of late decelerations. Late decelerations reflect uteroplacental insufficiency, not merely a monitoring artifact. Addressing the underlying physiological compromise is the priority before troubleshooting equipment.

Choice D rationale

Inserting a fetal scalp electrode provides a more accurate assessment of fetal heart rate by directly monitoring the fetus. However, this is an invasive procedure and is typically considered after initial conservative measures, such as maternal repositioning and oxygen administration, have been attempted without resolution of the late decelerations.

Choice A rationale

Restraining a child with autism can exacerbate distress and lead to further agitation due to sensory overload and a feeling of loss of control. Physical restraint can activate the sympathetic nervous system, increasing heart rate and cortisol levels, which can traumatize the child and hinder therapeutic rapport, contravening principles of trauma-informed care.

Choice B rationale

Hand flapping and rocking are common self-stimulatory behaviors, or "stimming," in children with autism, serving to regulate sensory input and manage anxiety. Allowing these behaviors in a low-stimulus environment supports emotional regulation by reducing external stressors and promoting a sense of security, which is crucial for individuals with sensory processing differences.

Choice C rationale

Immediately redirecting or attempting to stop self-stimulatory behaviors can be counterproductive for a child with autism. These behaviors often serve a vital self-regulatory function; interrupting them without providing an alternative coping mechanism can increase anxiety, frustration, and escalate behavioral challenges, disrupting their internal equilibrium.

Choice D rationale

Engaging in verbal interaction to distract a child with autism during self-soothing can disrupt their regulatory process. Children with ASD often have difficulties with social communication and may find unexpected verbal input overwhelming, potentially increasing sensory overload and agitation, rather than providing effective distraction or comfort.