A 35-year-old pregnant client at 34 weeks gestation with aortic stenosis is admitted to the labor and delivery unit with signs of congestive heart failure, including increasing dyspnea, orthopnea, and bilateral lower extremity edema. Which nursing intervention should be the priority?

Pathophysiology and Hemodynamic Goals

Pregnancy increases blood volume by up to 50%, significantly elevating preload. In mitral or aortic stenosis, the fixed valve obstruction prevents accommodation of this volume, causing backward flow into the pulmonary vasculature. This manifests as dyspnea, orthopnea, and edema. The primary nursing goal is to reduce venous return (preload) to decrease pulmonary congestion.

Priority Nursing Interventions

• Positioning First: Immediately place the client in high Fowler's position with legs in a dependent position. This uses gravity to pool blood in the extremities, reducing venous return to the right heart and relieving pulmonary congestion. This is the fastest, non-invasive intervention to optimize hemodynamics.
• Oxygen Therapy: Administer supplemental oxygen to maintain SpO2 above 95%. This is a supportive measure to improve oxygenation but does not correct the underlying preload issue.
• Pharmacologic Management: Administer prescribed diuretics intravenously after positioning to further reduce preload. Monitor urine output, electrolytes, and blood pressure closely. Beta-blockers may be used cautiously to control heart rate if atrial fibrillation is present, but always verify the order with the provider given pregnancy considerations.
• Continuous Monitoring: Assess maternal vital signs, lung sounds, SpO2, and fetal heart rate every 15 minutes during the acute phase. Monitor for signs of pulmonary edema (crackles, pink frothy sputum) and worsening heart failure.
• Delivery Planning: Prepare for a multidisciplinary discussion involving obstetrics, cardiology, and anesthesiology. Vaginal delivery with assisted second stage and regional anesthesia is often preferred to minimize cardiovascular stress. Cesarean delivery is reserved for obstetric indications or refractory maternal decompensation.

Key Safety Considerations

• Avoid placing the client in a supine or Trendelenburg position, which increases venous return and worsens pulmonary congestion.
• Do not administer IV fluid boluses unless specifically ordered for hypotension, as this will exacerbate heart failure.
• Recognize that sudden onset of severe dyspnea, tachypnea, and hypoxemia may indicate acute pulmonary edema, a life-threatening emergency requiring immediate escalation.