A 37-week primigravida tells the nurse, "I feel like my baby dropped.

I can finally take a deep breath again, but now I have to go to the bathroom all the time.”. Which nursing response is most appropriate?

Choice A rationale

Encouraging frequent breast stimulation and milk expression, whether manual or with a pump, stimulates increased prolactin and oxytocin release. This increases milk production, which is counterproductive for a client who chooses not to breastfeed and wishes to suppress lactation to reduce painful engorgement.

Choice B rationale

Applying warmth, such as warm compresses or showers, increases circulation and promotes the let-down reflex, thereby stimulating milk production and flow. This action would worsen the client's engorgement and prolong the discomfort for a client who is not breastfeeding and is trying to suppress lactation.

Choice C rationale

Manually expressing milk provides temporary relief but, similar to stimulation, signals the body to continue producing milk, thereby prolonging engorgement and the discomfort associated with the process of lactation suppression. Milk removal should be avoided or minimized for non-breastfeeding clients.

Choice D rationale

Applying cold compresses (e.g., ice packs, chilled cabbage leaves) helps to reduce swelling, vasoconstrict the blood vessels, and decrease inflammation and pain associated with breast engorgement. A firm, supportive bra minimizes breast movement and stimulation, which effectively suppresses lactation and relieves discomfort.

Choice A rationale

. A sudden drop in fetal heart rate (FHR) to 70 beats per minute after rupture of membranes, accompanied by variable decelerations that do not resolve with maternal repositioning, strongly suggests umbilical cord compression or prolapse. The immediate, priority action is a sterile vaginal examination to confirm or rule out a prolapsed cord. If the cord is palpated, the nurse must maintain continuous pressure on the presenting part to lift it off the cord while simultaneously initiating emergency protocols for delivery. This action directly addresses the potentially life-threatening cause of fetal compromise.

Choice B rationale

. Magnesium Sulfate is an anticonvulsant and tocolytic agent primarily used to prevent seizures in preeclampsia or for fetal neuroprotection, and occasionally to relax the uterus for an arrest of labor. It is not indicated for acute fetal bradycardia or variable decelerations resulting from potential cord compression. Administering this medication would delay the critical assessment and intervention required to stabilize the fetal heart rate, which is the immediate clinical priority in this emergency situation.

Choice C rationale

. Checking maternal vital signs is an important component of the initial assessment, as maternal hypotension or fever could cause fetal distress. However, in the setting of spontaneous rupture of membranes followed immediately by severe, unresolving fetal bradycardia (70 bpm), the highest priority is to rule out umbilical cord prolapse, which requires immediate intervention. The vital sign check can be performed by another staff member while the nurse performs the essential vaginal examination.

Choice D rationale

. Oxytocin is a synthetic uterotonic hormone used to induce or augment labor by stimulating uterine contractions. Increasing its infusion rate would intensify uterine activity, potentially worsening the already compromised fetal oxygenation due to cord compression. Stronger contractions would further decrease blood flow through the intervillous spaces and increase pressure on a potentially prolapsed or compressed cord, escalating the fetal distress rather than resolving it.