The nurse is caring for a 37-weeks gestation infant born to a parent with hepatitis B. Which intervention will the nurse include in the plan of care?

Choice A reason: Placing the patient in a supine position is not recommended in cases of suspected partial placental abruption. The supine position can compress the inferior vena cava, reducing blood flow to the placenta and potentially worsening the condition. Instead, a lateral position is generally preferred to enhance blood flow.

Choice B reason: Encouraging oral intake is not a priority action in this scenario. In cases of suspected placental abruption, the patient may need to undergo emergency medical procedures, and maintaining an empty stomach is often advised to prevent aspiration if anaesthesia is required.

Choice C reason: Administering IV fluids is crucial in managing suspected partial placental abruption. This intervention helps maintain maternal blood pressure and ensures adequate blood flow to the placenta, which is essential for fatal well-being. IV fluids can also be vital in managing any potential blood loss.

Choice D reason: Evaluating fatal heart rate monitoring is essential to assess the foetus’s well-being. Continuous monitoring allows the healthcare team to detect any signs of fatal distress, which can guide further medical interventions and decision-making processes.

Choice E reason: Monitoring maternal pain is a critical component of managing suspected partial placental abruption. Pain assessment helps determine the severity of the abruption and the effectiveness of pain management strategies. It also provides valuable information about the patient's condition and the need for additional interventions.

Choice A reason: Informing the patient that they are in latent Labor is appropriate in this situation. Latent Labor, also known as early Labor, is characterized by cervical dilation of up to 3 cm and mild contractions that may last for several hours or even days. It is important to educate the patient about the early stages of Labor and what to expect as it progresses.

Choice B reason: Initiating Labor augmentation is not necessary at this point. Labor augmentation is typically used when Labor is not progressing adequately. In this case, the patient is in the early stages of Labor, and there is no indication that augmentation is needed.

Choice C reason: Preparing the patient for a caesarean delivery is not warranted based on the information provided. The patient's condition does not suggest any immediate need for a caesarean section, and the Labor is still in its early stages.

Choice D reason: Anticipating admission to the Labor and delivery unit may not be required at this stage. Since the patient is in latent Labor, they may be advised to stay at home until Labor progresses further and the contractions become more intense and frequent. This helps reduce unnecessary hospital admissions and allows the patient to be more comfortable in their home environment.