The nurse will implement the following interventions based on the fetal heart rate.
(Select All that Apply.)

Choice A rationale

The pulsating cord felt in the vagina indicates umbilical cord prolapse, a critical obstetric emergency. Immediately applying upward pressure to the presenting fetal part (vertex) manually elevates the fetus off the prolapsed cord. This action aims to relieve pressure on the umbilical vessels, thereby preventing fetal hypoxia and maintaining oxygen supply to the fetus until delivery can be expedited.

Choice B rationale

While continuous fetal monitoring is essential, adjusting the monitor is not the immediate priority in the presence of a prolapsed umbilical cord and a significantly decreased fetal heart rate. The immediate intervention is to relieve pressure on the cord to improve fetal oxygenation.

Choice C rationale

Calling the provider and preparing for an emergency cesarean section are necessary steps that should follow the immediate intervention. However, the very first action must be to relieve pressure on the prolapsed cord to prevent fetal compromise.

Choice D rationale

Positioning the client on her left side is a standard intervention for fetal distress or suspected vena cava syndrome, but in the case of a prolapsed umbilical cord, it is not the most immediate and effective action. Direct pressure on the presenting part is required to alleviate cord compression. .

Choice A rationale

While magnesium sulfate can sometimes lead to a mild diuresis, its primary therapeutic effect in severe preeclampsia is not a direct reduction in swelling and fluid retention. These symptoms are more effectively managed by addressing the underlying hypertension and potential fluid overload through other interventions.

Choice B rationale

Magnesium sulfate is primarily used as an anticonvulsant and to lower blood pressure in severe preeclampsia. While it might indirectly alleviate some discomfort associated with preeclampsia, a direct reduction in pain and headaches is not the primary indicator of its therapeutic effectiveness.

Choice C rationale

Magnesium sulfate does have antihypertensive properties and can help lower blood pressure in severe preeclampsia. However, its most critical role is in preventing seizures. Therefore, monitoring blood pressure alone is not the most appropriate way to determine if the medication is working effectively in preventing seizures. Normal blood pressure is typically less than 120/80 mmHg.

Choice D rationale

Magnesium sulfate is administered in severe preeclampsia primarily to prevent seizures and may also have a relaxing effect on smooth muscles, which can improve hyperreflexia. A decrease in seizure activity and the normalization of deep tendon reflexes (normal range is 2+) are key indicators that the magnesium sulfate is achieving its therapeutic goals.