Which of the following interventions should a nurse implement first for a client who is at 38 weeks of gestation and has a nonstress test showing a series of late decelerations?

Elevate the client's legs.

Administer lactated Ringer's via IV bolus.

Prepare the client for a cesarean birth.

Place the client in a lateral position.

Answer and Explanation

The Correct Answer is D

Choice A reason: Elevating the client’s legs does not address late decelerations, which indicate uteroplacental insufficiency. This position may reduce venous return, worsening maternal cardiac output and placental perfusion. Late decelerations require interventions to improve fetal oxygenation, such as repositioning or oxygen, not leg elevation, which is irrelevant to fetal distress.

Choice B reason: Administering lactated Ringer’s via IV bolus addresses maternal hypotension but is not the first intervention for late decelerations. Positioning improves placental perfusion immediately, while fluids take longer to act. Late decelerations reflect fetal hypoxia from reduced uteroplacental blood flow, requiring urgent repositioning to optimize circulation before secondary measures like fluids.

Choice C reason: Preparing for cesarean birth is not the first intervention for late decelerations, as intrauterine resuscitation (e.g., lateral positioning) may resolve fetal hypoxia. Cesarean is considered if decelerations persist despite interventions. Immediate surgical preparation delays reversible measures, risking unnecessary maternal morbidity while bypassing simpler methods to restore fetal oxygenation.

Choice D reason: Placing the client in a lateral position is the first intervention for late decelerations, as it relieves uterine pressure on the inferior vena cava, improving maternal cardiac output and placental perfusion. This corrects fetal hypoxia by enhancing uteroplacental blood flow, addressing the physiological cause of decelerations, per obstetric emergency protocols.

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Correct Answer is ["A","E"]

Explanation

Choice A reason: The Tdap vaccine (diphtheria-acellular pertussis) is recommended at 27-36 weeks to transfer maternal antibodies, protecting newborns from pertussis. Pertussis causes severe respiratory illness in infants, and maternal immunization boosts IgG antibodies, crossing the placenta to provide passive immunity until the infant’s vaccination, per immunological guidelines.

Choice B reason: Varicella vaccine, a live-attenuated virus, is contraindicated in pregnancy due to theoretical fetal risks. Live vaccines can cross the placenta, potentially causing congenital varicella syndrome, affecting fetal development. Vaccination is deferred until postpartum to avoid these risks, as the immune response could harm the fetus, per obstetric immunization protocols.

Choice C reason: Human papillomavirus (HPV) vaccine is not recommended during pregnancy, as its safety is unestablished. HPV vaccination prevents cervical cancer, not perinatal infections, and is deferred until postpartum. The vaccine’s inactivated nature poses no direct fetal risk, but lack of pregnancy-specific efficacy data prioritizes other vaccines like Tdap and influenza.

Choice D reason: Measles, mumps, and rubella (MMR) vaccine, a live-attenuated virus, is contraindicated in pregnancy due to risks of congenital rubella syndrome, which causes fetal anomalies. The immune response could theoretically affect fetal development, so vaccination is postponed until postpartum to ensure maternal immunity without compromising fetal safety, per immunization guidelines.

Choice E reason: Inactivated influenza vaccine is recommended during pregnancy, ideally in the second or third trimester, to protect against flu-related complications. Influenza increases maternal morbidity and preterm birth risk. The vaccine stimulates IgG production, crossing the placenta to provide neonatal immunity, reducing respiratory illness risks in both mother and infant, per obstetric protocols.

A. A client who is at 28 weeks of gestation and has mitral valve stenosis. B. A client who is at 32 weeks of gestation and has a positive Kleihauer-Betke test. C. A client who is at 30 weeks of gestation and has cystic fibrosis. D. A client who is at 36 weeks of gestation and has severe chronic hypertension.

Correct Answer is D

Explanation

Choice A reason: Mitral valve stenosis at 28 weeks increases cardiac workload, risking heart failure or arrhythmias due to increased blood volume in pregnancy. However, it does not directly cause seizures. Seizure risk is linked to neurological or hypertensive conditions, not cardiac valvular issues, which primarily affect hemodynamic stability and not seizure thresholds.

Choice B reason: A positive Kleihauer-Betke test at 32 weeks indicates fetal-maternal hemorrhage, requiring Rho(D) immune globulin to prevent isoimmunization. It does not increase seizure risk, as it affects blood compatibility, not neurological stability. Seizures are unrelated to this hematological issue, which primarily impacts future pregnancies rather than maternal neurological function.

Choice C reason: Cystic fibrosis at 30 weeks affects respiratory and pancreatic function, leading to infections or malabsorption, but not seizures. Seizure risk requires neurological or hypertensive triggers, not pulmonary or metabolic issues. The condition’s impact on maternal oxygenation does not directly alter seizure thresholds or neurological excitability in pregnancy.

Choice D reason: Severe chronic hypertension at 36 weeks increases seizure risk due to preeclampsia or eclampsia, where elevated blood pressure disrupts cerebral autoregulation, causing neuronal irritability. Seizure precautions are critical, as hypertension-induced endothelial damage and cerebral edema can trigger convulsions, threatening maternal and fetal safety, necessitating magnesium sulfate prophylaxis.

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Which of the following interventions should a nurse implement first for a client who is at 38 weeks of gestation and has a nonstress test showing a series of late decelerations?

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Correct Answer is D

Explanation

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