A nurse is providing teaching regarding the expected physiological and psychosocial changes to a client in the first trimester.

Select the appropriate nursing interventions for a client experiencing body image concerns related to pregnancy.

Select two options.

Choice A rationale

While any serious maternal infection or complication can theoretically increase the risk of adverse pregnancy outcomes, including miscarriage, HSV infection is not a primary risk factor for spontaneous abortion. The greatest risk associated with HSV in pregnancy is the transmission of the virus to the neonate, particularly during vaginal birth. Miscarriage is more commonly linked to chromosomal abnormalities, uterine factors, or other maternal health conditions. The focus of care in HSV is preventing perinatal transmission.

Choice B rationale

Maternal pain and discomfort associated with a herpes simplex virus (HSV) outbreak are indeed a concern for the pregnant woman. The lesions can be painful and distressing. However, from a medical and fetal health perspective, this is not the greatest concern. The pain and discomfort are temporary and can be managed with supportive care. The potential for serious, life-threatening consequences for the newborn far outweighs the maternal symptoms.

Choice C rationale

The greatest concern regarding maternal herpes simplex virus (HSV) infection is the potential for transmission to the newborn during delivery, especially if the mother has an active primary genital outbreak. Neonatal herpes is a serious and potentially fatal condition that can lead to disseminated disease, central nervous system involvement, or skin, eye, and mouth disease. The risk is highest with a primary infection near term, as the mother has not yet developed protective antibodies to pass to the fetus. A cesarean section is often recommended if active lesions are present.

Choice D rationale

The development of oral cold sores, caused by HSV-1, is generally not the primary concern in the context of pregnancy. While oral HSV can be transmitted to a newborn, the risk is typically much lower and the consequences less severe than with genital HSV transmission during delivery. The focus of concern for maternal-fetal health is primarily on genital herpes outbreaks, particularly a primary infection at the time of delivery, due to the high risk of severe neonatal morbidity and mortality

Choice A rationale

Notifying the provider stat is an appropriate action but it is not the immediate next step. The nurse must first implement interventions to address the uterine tachysystole and hypertonicity, which are causing a non-reassuring fetal status. The primary action is to stop the oxytocin to prevent further stress on the fetus.

Choice B rationale

The nurse should decrease the oxytocin rate because the client is experiencing uterine tachysystole, defined as more than five contractions in 10 minutes, and hypertonicity, indicated by the non-relaxed resting tone. This condition reduces uterine blood flow and oxygen to the fetus, so decreasing the oxytocin is the most immediate intervention to correct the problem.

Choice C rationale

Preparing the room for delivery is not an appropriate action at this time. The current issue is uterine tachysystole and hypertonicity, which indicates a risk to fetal well-being, not that delivery is imminent. The priority is to resolve the uterine overstimulation and reassess fetal tolerance of labor before considering delivery.

Choice D rationale

Placing oxygen is a supportive measure but not the primary intervention. While oxygen may help improve fetal oxygenation, the root cause is the excessive uterine activity, which is best addressed by decreasing or stopping the oxytocin infusion. Addressing the primary cause is the priority before implementing supportive measures.