G1P1, 37 weeks' gestation patient with a scheduled nonstress test (NST)

Complete the following sentence using the drop-down options.

The nurse's greatest concern is the client's risk of developing

__i_____

and related to

__ii____

and

___iii____

.

A. 32-week patient with preeclampsia receiving magnesium sulfate – Magnesium sulfate requires close monitoring for toxicity (e.g., respiratory depression, loss of deep tendon reflexes), making this client inappropriate for a nurse with no OB experience.

B. 9-week client with hyperemesis receiving IV therapy – This client is the most stable and requires routine care, such as IV fluid administration and antiemetics, making them the best assignment for a new nurse without OB experience.

C. 34-week client with no fetal heartbeat – This client requires significant emotional support and possibly induction of labor, making them inappropriate for a nurse unfamiliar with OB care.

D. 38-week client with complete previa – Placenta previa poses a high risk for hemorrhage, and this client requires close monitoring. A new nurse without OB experience would not be the best choice for this assignment.

A. Discontinue the oxytocin infusion The patient is not receiving an oxytocin infusion; therefore, discontinuing it is not applicable. Oxytocin is typically stopped in cases of uterine tachysystole or fetal distress, neither of which is present in this scenario. The fetal heart rate (FHR) is within normal range, and no contractions have been noted.

B. Notify the health care provider: The nurse should notify the healthcare provider because the patient is exhibiting severe hypertension (168/100 mmHg), minimal fetal heart rate variability, and laboratory findings consistent with preeclampsia with severe features (elevated liver enzymes, thrombocytopenia, and proteinuria).

C. Assist the patient onto her left side: Repositioning the patient onto her left side can improve uteroplacental blood flow by reducing pressure on the inferior vena cava, thereby enhancing oxygen delivery to the fetus.

D. Administer oxygen at 10L/min via nonrebreather face mask : Oxygen therapy is typically reserved for cases of acute fetal distress. In this case, the FHR is within the normal range, and there are no signs of immediate fetal compromise requiring supplemental oxygen.

E. Stop the magnesium sulfate: Magnesium sulfate is administered to prevent seizures in preeclampsia with severe features and should not be stopped unless there are signs of magnesium toxicity, such as absent deep tendon reflexes (DTRs), respiratory depression, or altered mental status.

F. Assist with a vaginal exam for cord prolapse: A vaginal examination for cord prolapse is only indicated when there is a sudden, severe fetal bradycardia or variable decelerations, particularly following rupture of membranes.