A 13-year-old with a history of bulimia nervosa is brought to the clinic for fatigue and irregular heartbeat.
Which assessment finding would require immediate intervention?

Choice A rationale

A fundus that is deviated to the right, boggy, and 2 cm above the umbilicus suggests a distended bladder is displacing the uterus, preventing it from contracting effectively. A full bladder inhibits uterine involution by impeding the muscle fibers from compressing blood vessels, leading to uterine atony and increasing the risk of postpartum hemorrhage. Normal bladder capacity is 300-500 mL.

Choice B rationale

Obtaining a stat hemoglobin level is not the immediate priority. While a boggy uterus can indicate blood loss, the primary issue here is likely bladder distension causing uterine atony. Addressing the cause of the uterine displacement (bladder distension) takes precedence over assessing the degree of blood loss, which would be a secondary consequence. A normal hemoglobin for a woman is typically 12.0 to 15.5 grams per deciliter.

Choice C rationale

Administering methylergometrine is not the first action. Methylergometrine is a uterotonic agent used to promote uterine contractions and prevent postpartum hemorrhage. However, if the uterus is displaced by a full bladder, the medication's effectiveness will be significantly reduced until the bladder is emptied. Treating the underlying cause is crucial before administering uterotonics.

Choice D rationale

Inserting an indwelling urinary catheter is a more invasive intervention than assisting the client to void. While a catheter might be necessary if the client cannot void independently, the initial and least invasive action should always be to encourage spontaneous urination. Catheterization carries risks of urinary tract infection and discomfort, so it's not the first-line intervention.

Choice A rationale

Variable decelerations are abrupt, unpredictable decreases in fetal heart rate, often V, W, or U shaped. They are caused by umbilical cord compression, which reduces umbilical blood flow, leading to hypoxia and acidemia. This compromises fetal oxygenation and can indicate fetal distress requiring intervention to optimize fetal well-being.

Choice B rationale

Early decelerations are symmetrical, gradual decreases in fetal heart rate that mirror uterine contractions. They are caused by head compression during labor, stimulating the vagus nerve and slowing the heart rate. This is generally considered a benign finding and indicates normal fetal response to uterine contractions.

Choice C rationale

Decreased fetal heart rate (FHR) variability refers to a reduction in the normal fluctuations of the FHR. This indicates reduced central nervous system (CNS) oxygenation and autonomic nervous system activity, often due to fetal hypoxia, acidemia, or CNS depressant medications. Sustained decreased variability is a significant nonreassuring sign.

Choice D rationale

Absent accelerations mean the fetal heart rate does not spontaneously increase by 15 beats per minute for at least 15 seconds. Fetal accelerations indicate a healthy, oxygenated fetal central nervous system and are a sign of fetal well-being. Their absence suggests potential fetal hypoxemia or acidosis.

Choice E rationale

A fetal heart rate baseline higher than expected, typically above 160 beats per minute, is classified as fetal tachycardia. This can be caused by maternal fever, infection, fetal hypoxia, or certain medications. Sustained tachycardia can increase fetal metabolic demand and potentially lead to fetal decompensation.