Exhibits Complete the following sentence by using the list of options The nurse should first address the client’s dropdownfollowed by the client’sdropdown
Explanation & Rationale
Rationale for Correct Options: Late decelerations on fetal heart rate (FHR) – First Priority Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. This is the most urgent concern because prolonged fetal distress can lead to hypoxia and acidosis, increasing the risk of complications such as stillbirth or emergency cesarean birth. Nursing Actions: Reposition the client to left lateral position to improve placental perfusion. Administer oxygen at 10 L/min via a non-rebreather mask. Increase IV fluids to improve maternal circulation. Stop oxytocin if it's being used, as it may be causing excessive contractions. Notify the provider immediately for further interventions, such as potential intrauterine resuscitation or emergent delivery. Positive Group B streptococcus (GBS) status – Second Priority The client tested positive for GBS, a bacterial infection that can be transmitted to the newborn during birth, leading to neonatal sepsis, pneumonia, or meningitis. While this is a significant concern, it is secondary to the immediate fetal distress from late decelerations. Nursing Actions: Administer IV antibiotics (penicillin G or an alternative) as ordered to prevent neonatal infection. Monitor for signs of infection in the newborn after delivery. Rationale for Incorrect Options: Severe back pain rated 10/10 – Pain management is important, but fetal distress takes precedence over maternal discomfort. Restlessness and irritability – These could indicate maternal distress or labor progression, but they are not as urgent as fetal oxygenation. Increasing contraction intensity and frequency – This is expected as labor progresses but is not immediately life-threatening. Fatigue and emotional distress – While support is essential, it is not a priority over fetal well-being or preventing neonatal infection.