A pregnant client at 28 weeks gestation with a history of mitral valve stenosis is admitted to the labor and delivery unit with signs of cardiac decompensation. Which nursing intervention should be the priority?
1Position the client in semi-Fowler's position with lateral tilt✓ 정답
2Administer oxygen at 2 L/min via nasal cannula
3Prepare for immediate cesarean delivery
4Increase IV fluid rate to maintain adequate preload
해설
Positioning in semi-Fowler's with lateral tilt is the priority as it immediately reduces venous return and prevents supine hypotension, optimizing cardiac function. Oxygen, cesarean delivery, and IV fluids are secondary interventions.
Clinical Judgment
The core of this problem is determining the most immediate and highest-priority nursing intervention for a patient with cardiac decompensation in late pregnancy. In mitral stenosis, blood flow from the left atrium to the left ventricle is restricted, increasing left atrial pressure, and the increased blood volume from pregnancy easily leads to pulmonary congestion and edema. Therefore, reducing cardiac workload and optimizing breathing and circulation is the top priority. The semi-Fowler's position with a lateral tilt reduces venous return (preload) to decrease cardiac workload, prevents compression of the inferior vena cava to maintain cardiac output, and aids chest expansion—making it an immediate, non-invasive first-line intervention. All other interventions are considered after this basic physiological adjustment.
Memory Tip:
Positioning is Priority for Pregnant cardiac patients. For pregnant patients with heart problems, position change is the top priority. Or remember "Sit up and Tilt."
KR vs US:
In Korea, the principles of positioning management for pregnant women with cardiac disease are the same, but there may be differences in the emphasis on education or the application of standardized protocols regarding the importance and implementation of the lateral tilt position in clinical settings. The NGN assesses immediate judgment based on these physiological principles.
Clinical Practice GuideThe first step in managing a patient with cardiac decompensation during pregnancy is always repositioning. Elevate the upper body to a semi-Fowler's position (30-45 degrees) and tilt the patient 15-30 degrees to the right or left to prevent the uterus from compressing the inferior vena cava. This is a simple but most effective intervention for maintaining cardiac output and relieving dyspnea.Caution:In SATA (Select All That Apply) questions, "oxygen administration" may be included, but in this scenario, repositioning is the single best answer with higher priority. Oxygen should be provided immediately after repositioning, but it does not address the underlying venous return issue. Additionally, increasing fluids in a patient with mitral stenosis is a fatal mistake that can increase the risk of pulmonary edema.
Mitral Valve Stenosis (승모판 협착증) — Narrowing of the mitral valve between the left atrium and left ventricle, restricting blood flow. This causes increased left atrial pressure and pulmonary congestion.
Cardiac Decompensation (심장 대상부전) — A condition in which the heart fails to pump enough blood to meet the body's metabolic demands. Symptoms include shortness of breath, fatigue, and peripheral edema.
Semi-Fowler's Position (반좌위) — Position the upper body elevated at about 30-45 degrees. This helps relieve breathing difficulty, reduce venous return, and promote chest expansion.
Lateral Tilt (측면 경사 자세) — A position where the pregnant woman lies on her back and tilts 15-30 degrees to one side. This prevents compression of the inferior vena cava to maintain cardiac output.
Supine Hypotensive Syndrome (앙와위 저혈압 증후군) — Supine hypotensive syndrome in late pregnancy: when a pregnant woman lies on her back, the enlarged uterus compresses the inferior vena cava, reducing venous return and cardiac output, leading to hypotension, dizziness, and fainting.