# A pregnant client at 32 weeks gestation with a history of mitral valve stenosis is admitted to the labor and delivery unit with complaints of increasing dyspnea and fatigue. Her vital signs are: BP 110/70 mmHg, HR 110 bpm, RR 28/min, O2 sat 92% on room air. What is the priority nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542859 > language: ko > subject: Maternal Newborn Health ## 문제 A pregnant client at 32 weeks gestation with a history of mitral valve stenosis is admitted to the labor and delivery unit with complaints of increasing dyspnea and fatigue. Her vital signs are: BP 110/70 mmHg, HR 110 bpm, RR 28/min, O2 sat 92% on room air. What is the priority nursing intervention? ## 보기 1. Position the client in semi-Fowler's position and administer oxygen as ordered **✔ 정답** 2. Encourage the client to ambulate to improve circulation 3. Increase fluid intake to maintain adequate blood volume 4. Place the client in Trendelenburg position to improve venous return **정답: 1** ## 해설 The client shows signs of cardiac decompensation (tachycardia, tachypnea, low O2 sat). Priority is to improve oxygenation and reduce cardiac workload by positioning in semi-Fowler's and administering oxygen. Other options (ambulation, increased fluids, Trendelenburg) would increase cardiac strain. ## 심화 해설 Understanding the Clinical Scenario The client is at 32 weeks gestation, a period of peak physiological cardiovascular stress. She has a history of mitral valve stenosis, a structural heart disease that obstructs blood flow from the left atrium to the left ventricle. Her symptoms of increasing dyspnea, fatigue, and a heart rate of 110 bpm with an oxygen saturation of 92% on room air indicate she is decompensating. This clinical picture is consistent with developing pulmonary edema secondary to elevated left atrial pressure, a hallmark complication of mitral stenosis. The physiological plasma volume expansion of pregnancy, which peaks around this gestational age, further exacerbates the pressure gradient across the stenotic valve, overwhelming the heart's ability to compensate . Analysis of the Priority Intervention The priority is to immediately reduce the work of breathing and improve oxygenation, which directly addresses the pathophysiological cascade of post-capillary pulmonary hypertension. In mitral stenosis, the obstruction creates a "back-pressure" into the pulmonary vasculature, a form of post-capillary pulmonary hypertension [1]. This increases pulmonary capillary hydrostatic pressure, forcing fluid into the alveoli and impairing gas exchange. - Positioning in semi-Fowler's position is critical because it uses gravity to reduce venous return to the right heart. This, in turn, decreases pulmonary blood volume and lowers hydrostatic pressure in the pulmonary capillaries, directly relieving the driving force behind the pulmonary edema. It also allows for maximal chest expansion, reducing the work of breathing. - Administering oxygen as ordered corrects the hypoxemia (O2 sat 92%), which is essential to meet the increased metabolic demands of the mother and fetus and to prevent further cardiac decompensation from myocardial hypoxia. Why the Other Options are Incorrect - Option 2: Encourage the client to ambulate. Ambulation increases metabolic demand and cardiac workload. In a client with a fixed cardiac output lesion like mitral stenosis, the heart cannot increase output to meet the demand, which would worsen dyspnea and could precipitate acute pulmonary edema. - Option 3: Increase fluid intake. This is contraindicated. The pathophysiology of the problem is pulmonary congestion from fluid overload relative to the heart's pumping capacity. Increasing intravascular volume would directly increase left atrial and pulmonary capillary pressures, severely worsening pulmonary edema. - Option 4: Place the client in Trendelenburg position. This position increases venous return to the heart. In a client with mitral stenosis, the left ventricle cannot effectively receive this increased volume, causing it to pool in the pulmonary circulation. This would dramatically elevate pulmonary capillary pressure and accelerate the development of life-threatening pulmonary edema. This is the most dangerous option for this client. The immediate, non-pharmacological intervention that targets the underlying hemodynamic derangement—reducing pulmonary venous congestion while supporting oxygenation—is to position the client in semi-Fowler's position and administer oxygen. This aligns with the proactive approach needed for managing serious symptoms in pregnant women with structural heart disease .References (research sources) - [1]Cardiovascular-obstetric state-of-the-art review: pulmonary hypertension in pregnancy.Research articleOng JYS, Yap JJY, Choolani M, Poh KK, Dashraath P, Low TT. (2025) · DOI: 10.4103/singaporemedj.smj-2024-198 ## 임상 시나리오 Clinical Management of Decompensated Mitral Stenosis in Pregnancy Immediate Nursing Priorities - Position the client in a high Fowler's or semi-Fowler's position (head of bed 45-60 degrees) with legs dependent to immediately reduce venous return and pulmonary congestion. - Administer supplemental oxygen via face mask to maintain SpO2 above 95%, reducing myocardial oxygen demand and alveolar hypoxia. - Notify the provider and prepare for potential transfer to a monitored cardiac or intensive care unit. - Maintain strict intake and output monitoring; anticipate fluid restriction to prevent volume overload. Pathophysiology-Driven Rationale - The physiological 40-50% increase in blood volume peaks at 32-34 weeks, critically increasing the pressure gradient across a stenotic mitral valve. - Obstructed left atrial emptying causes post-capillary pulmonary hypertension, elevating hydrostatic pressure and forcing fluid into the alveoli. - Tachycardia (HR 110 bpm) shortens diastolic filling time, further increasing left atrial pressure and decreasing cardiac output. Interventions to Avoid - Do not place the client flat or in Trendelenburg; this increases venous return and can precipitate acute pulmonary edema. - Avoid strenuous activity or ambulation that increases cardiac workload and oxygen consumption. - Do not administer large volumes of IV fluids; use a conservative fluid strategy to prevent volume overload. Ongoing Monitoring and Collaborative Care - Continuously monitor heart rate, respiratory rate, SpO2, and blood pressure for signs of worsening heart failure. - Auscultate lung fields frequently for crackles indicating progressing pulmonary edema. - Prepare for potential medical interventions including diuretics (e.g., furosemide) and beta-blockers to control heart rate and improve diastolic filling. - Collaborate with cardiology and maternal-fetal medicine for delivery planning; vaginal delivery with epidural anesthesia and assisted second stage is often preferred to minimize cardiac stress. ## 핵심 개념 - **Mitral Valve Stenosis** — Narrowing of the mitral valve orifice obstructing blood flow from the left atrium to the left ventricle, leading to increased left atrial pressure and pulmonary congestion. - **Semi-Fowler's Position** — A seated or semi-reclined position (head of bed elevated 30-45 degrees) that reduces venous return and decreases the work of breathing. - **Post-capillary Pulmonary Hypertension** — Elevated pressure in the pulmonary veins and capillaries due to downstream obstruction, such as mitral stenosis, causing fluid leakage into the alveoli. - **Pulmonary Edema** — Accumulation of fluid in the lung alveoli, often caused by high pulmonary capillary pressure, impairing gas exchange and causing dyspnea. - **Physiological Hypervolemia of Pregnancy** — A normal 40-50% increase in maternal blood volume peaking around 32-34 weeks gestation, which can worsen pre-existing cardiac conditions. ## 같은 주제 문제 - [A nurse is assessing a pregnant client at 28 weeks gestation with a history of mitral valv…](https://mymerci.kr/pages/nclex_q.php?qn_id=542854) - [A 28-year-old pregnant woman at 32 weeks gestation with a history of mitral valve stenosis…](https://mymerci.kr/pages/nclex_q.php?qn_id=542855) - [A 25-year-old pregnant woman at 30 weeks gestation with a history of peripartum cardiomyop…](https://mymerci.kr/pages/nclex_q.php?qn_id=542856) - [A pregnant client at 28 weeks gestation with a history of mitral valve stenosis is admitte…](https://mymerci.kr/pages/nclex_q.php?qn_id=542857) - [A 35-year-old pregnant client at 34 weeks gestation with aortic stenosis is admitted to th…](https://mymerci.kr/pages/nclex_q.php?qn_id=542858) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._