A client in labor and delivery has just received a dose of ephedrine.
Which of the following signs should the nurse expect to see?

Choice A rationale

Sepsis is a generalized infection, and while any systemic infection is a relative contraindication to an epidural due to the risk of spreading the infection to the central nervous system, local site infection is the primary concern, and sepsis is not the most common or specific hematological contraindication.

Choice B rationale

Thrombocytopenia, characterized by a platelet count below the normal range of 150,000 to 450,000/microL, significantly increases the risk of epidural hematoma formation at the puncture site, which can lead to spinal cord compression and permanent neurological damage, making it a critical contraindication for epidural placement.

Choice C rationale

The extent of cervical dilation is not an absolute contraindication for an epidural, as it can be placed even in active labor (4-7 cm) or occasionally later, although the effectiveness may be reduced if placed very close to delivery; a 5 cm dilation is generally an acceptable time for placement.

Choice D rationale

Anemia, defined as a low red blood cell count or hemoglobin level (normal Hgb for pregnant women is >11 g/dL in the first and third trimesters, >10.5 g/dL in the second), does not affect the risk of hemorrhage or neurological complications associated with epidural insertion and is therefore not a specific contraindication.

Choice A rationale

Telling the woman to push immediately upon full dilation is often discouraged as it does not allow for a period of rest or passive descent, which is beneficial for both maternal and fetal well-being, especially if the urge to push is not yet overwhelming. Pushing should ideally be driven by the woman's involuntary urge, often called 'laboring down' or delayed pushing. This conserves maternal energy and may improve fetal oxygenation by reducing the number of sustained pushing efforts.

Choice B rationale

Sustained, closed-glottis pushing, where the woman holds her breath and pushes for 10-15 seconds, increases intrathoracic and intra-abdominal pressure. This can lead to decreased venous return to the heart, resulting in reduced maternal cardiac output and blood pressure. Consequently, this diminishes blood flow to the placenta and can cause fetal hypoxia or nonreassuring fetal heart rate patterns, making it a generally unfavorable pushing technique.

Choice C rationale

While an epidural can provide effective pain relief, it may slow the progress of the second stage of labor by reducing the woman's urge and ability to spontaneously push, especially with dense motor blockade. Furthermore, the timing of the epidural placement, particularly initiating it during the second stage, is not a primary measure to enhance fetal descent, which relies more on gravity and effective pushing efforts.

Choice D rationale

Encouraging upright positions like squatting or having the head of the bed up utilizes the force of gravity to assist fetal descent and rotation through the pelvis. These positions also promote uterine contractility and allow for optimal maternal-pelvic alignment. Squatting, in particular, increases the capacity of the pelvic outlet by 10.