The nurse is caring for a client at 32 weeks gestation with uterine contractions who is receiving nifedipine.

What will the nurse consider the priority assessment finding related to nifedipine therapy that requires further action?

Prenatal assessment at 22 weeks focuses on monitoring fetal growth and maternal well-being. Nurses must apply knowledge of gestational milestones and anatomical landmarks. Assessing the fundus provides a non-invasive way to confirm that fetal development is progressing appropriately.

Choice A rationale

Fundal height measurement begins around 20 weeks. At 22 weeks, the fundus is typically located slightly above the umbilicus. This measurement in centimeters should correlate with the weeks of gestation to screen for appropriate fetal growth.

Choice B rationale

Routine vaginal exams are not indicated at 22 weeks unless the patient reports symptoms of preterm labor, leaking fluid, or bleeding. Unnecessary exams increase the risk of infection and are not part of a standard visit.

Choice C rationale

Leopold's maneuvers are used to determine fetal lie, presentation, and position. These are typically performed in the third trimester, around 36 weeks, when the fetus is large enough to palpate clearly through the abdomen.

Choice D rationale

Pregnancy history, including gravidity and parity, is collected during the initial prenatal intake visit. While updated at each visit for new symptoms, it is not a specific physical assessment tool like measuring the fundal height.

Management of high-risk obstetric clients requires prioritizing physiological stability and fetal surveillance. This scenario demands application of nursing prioritization, understanding of respiratory support, fetal monitoring standards, and invasive procedure initiation to address potential complications while ensuring provider communication for collaborative care.

Choice A rationale

Provider notification is essential when laboratory values deviate from normal ranges, such as hemoglobin below 11 g/dL. This ensures timely medical orders for interventions that fall outside independent nursing scope, facilitating comprehensive medical management and safety.

Choice B rationale

Supplemental oxygen increases maternal arterial oxygen tension, optimizing placental perfusion and fetal oxygenation. Maintaining oxygen saturation ≥ 94 percent is critical in preventing fetal hypoxia during periods of maternal physiological stress or potential respiratory compromise.

Choice C rationale

Acetaminophen is an antipyretic and analgesic but is rarely a priority intervention in acute potential crises. Unless a significant fever ≥ 100.4 degrees Fahrenheit exists, other physiological stabilizing measures take precedence for immediate maternal-fetal safety.

Choice D rationale

Electronic fetal monitoring provides continuous data on fetal heart rate patterns and uterine activity. Normal fetal heart rate is 110 to 160 beats per minute. This assessment is vital for identifying early signs of fetal distress.

Choice E rationale

Establishing intravenous access is a priority for rapid fluid resuscitation or medication administration. Maintaining patency allows for immediate intervention if blood pressure drops below 90/60 mmHg or if emergency blood products are required for stabilization.