The nurse is caring for a pregnant client with heart disease undergoing labor. All of the following are appropriate nursing interventions, except:
The nurse is caring for a pregnant client with heart disease undergoing labor. All of the following are appropriate nursing interventions, except:
A. Attach the client to a cardiac monitor and place an external fetal monitor.
[5%]
B. Manage pain early in labor.
[11%]
C. Use controlled pushing efforts.
[21%]
D. Encourage ambulation.
[63%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Labor/Delivery
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Analysis
Explanation
Choice D is correct. Bed rest should be maintained to conserve energy and decrease cardiac stress. In pregnant clients with heart disease, ambulation may increase cardiac workload and oxygen demand, potentially exacerbating cardiac symptoms or compromising maternal and fetal well-being.
Choice A is incorrect. This intervention is crucial for continuous monitoring of the client's cardiac status and the fetal heart rate during labor. It allows for early detection of any cardiac complications or signs of fetal distress, enabling timely interventions to optimize outcomes for both the mother and baby.
Choice B is incorrect. Pain management is essential for promoting maternal comfort and reducing stress, which can help minimize the risk of cardiac complications in pregnant clients with heart disease.
Choice C is incorrect. Controlled pushing efforts, such as coached breathing techniques and controlled bearing-down efforts during the second stage of labor, can help prevent excessive strain on the client's cardiovascular system while promoting effective pushing and reducing the risk of maternal exhaustion or cardiac decompensation.
Additional Info
✓ According to the American College of Cardiology, approximately 0.2-4% of pregnancies are complicated by maternal heart disease, with congenital heart defects, valvular heart disease, and cardiomyopathies being common etiologies.
✓ Collaboration with a multidisciplinary team, including obstetricians, cardiologists, anesthesiologists, and neonatologists, is essential for managing pregnant clients with heart disease during labor.
✓ Nursing staff should be vigilant for any signs of cardiac decompensation, such as dyspnea, chest pain, or cyanosis, and promptly intervene as needed.
