A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate.
Select all nursing interventions that apply in the care for the client.

Choice A rationale

Nausea and vomiting are common discomforts of pregnancy, particularly in the first trimester. While they can be distressing, they are not typically indicative of an immediate life-threatening condition for the mother or fetus at 14 weeks gestation. Hyperemesis gravidarum, a more severe form, would warrant closer attention, but the description here is general.

Choice B rationale

Painless vaginal bleeding in the second or third trimester (28 weeks gestation) is a concerning sign and could indicate placenta previa or placental abruption, both of which can lead to significant maternal and fetal hemorrhage and compromise fetal oxygenation. This client requires immediate assessment to determine the cause and ensure prompt intervention if necessary.

Choice C rationale

A cough and fever at 38 weeks gestation could indicate an infection, such as influenza or pneumonia. While these conditions can be serious for a near-term pregnant woman and potentially affect the fetus, they are generally less immediately life-threatening than significant vaginal bleeding in the second or third trimester and would be addressed after the client with potential placental issues.

Choice D rationale

Missed period and vaginal spotting can be early signs of pregnancy or a threatened abortion. While it warrants investigation, it is generally not an immediate emergency requiring triage before a client with painless vaginal bleeding at 28 weeks gestation, which carries a higher risk of acute complications.

Choice A rationale

Fetal hypoxemia, a deficiency in oxygen reaching the fetal tissues, typically manifests as late decelerations in the fetal heart rate tracing, which reflect uteroplacental insufficiency. While severe hypoxemia can lead to various FHR patterns, variable decelerations are more directly associated with mechanical factors affecting the umbilical cord.

Choice B rationale

Altered fetal cerebral blood flow can be a consequence of various factors, including hypoxemia and cord compression, and can influence the fetal heart rate. However, variable decelerations are specifically caused by events that directly impede blood flow through the umbilical vessels rather than a generalized alteration in cerebral circulation.

Choice C rationale

Uteroplacental insufficiency, a condition where the placenta is unable to deliver an adequate supply of oxygen and nutrients to the fetus, typically results in late decelerations, indicating fetal distress due to chronic hypoxia. Variable decelerations, in contrast, have a more abrupt onset and recovery, reflecting acute changes in umbilical cord blood flow.

Choice D rationale

Umbilical cord compression occurs when the umbilical cord, which carries oxygen and nutrients to the fetus, is squeezed or constricted. This compression leads to a transient decrease in fetal blood flow and oxygenation, resulting in a rapid drop and subsequent return of the fetal heart rate, which is characteristic of variable decelerations. The shape, timing, and abrupt nature of variable decelerations directly correlate with the intermittent pressure on the umbilical cord.