When planning care for a laboring client, the practical nurse (PN) identifies the need to withhold solid foods while the client is in labor.
Which is the most important reason for this nursing intervention?

Choice A rationale

Protecting the myelomeningocele surgical incision from fecal contamination is paramount to prevent infection, as the defect is often located in the lumbosacral area. Fecal matter contains a high concentration of microorganisms, and any contamination could lead to serious central nervous system infections like meningitis.

Choice B rationale

The statement that the dressing will help dry the sutures for ease of removal is incorrect. Occlusive dressings are designed to maintain a moist wound environment, which promotes optimal wound healing and reduces scar formation, rather than drying sutures for removal.

Choice C rationale

Rapidly removing tape from the edges of the dressing is an incorrect technique. This can cause skin trauma, including stripping or tearing, especially in infants whose skin is delicate. Tape should be removed slowly and parallel to the skin to minimize epidermal injury.

Choice D rationale

The statement that the dressing should be dampened periodically to keep the skin incision moist is generally incorrect for surgical incisions once an occlusive dressing is applied. The occlusive dressing itself maintains a moist environment underneath, and external dampening could introduce pathogens and compromise the sterile field.

Choice A rationale

Performing deep tendon reflexes every 4 hours is primarily indicated for clients at risk of magnesium sulfate toxicity, not directly for fetal heart rate decelerations after the peak of contractions. These decelerations suggest uteroplacental insufficiency, where oxygen supply to the fetus is compromised, and magnesium sulfate is used for pre-eclampsia.

Choice B rationale

A left side-lying position alleviates compression of the inferior vena cava and aorta by the gravid uterus, thereby improving uteroplacental blood flow and oxygen delivery to the fetus. This physiological change can often resolve late decelerations, which are indicative of uteroplacental insufficiency due to reduced maternal blood flow.

Choice C rationale

Inserting an indwelling urinary catheter to monitor hourly output is essential for assessing fluid balance and renal perfusion, especially in high-risk pregnancies or those receiving intravenous fluids. However, it does not directly address or correct fetal heart rate decelerations caused by uteroplacental insufficiency.

Choice D rationale

Collecting a urine specimen for electrolytes and protein is a diagnostic measure for conditions like pre-eclampsia, which involves proteinuria and electrolyte imbalances. While important for overall maternal assessment, it does not provide an immediate intervention for late fetal heart rate decelerations.