A client is in labor and actively pushing.
The nurse observes decelerations in the fetal heart rate and the fetal head is at the vaginal station.



What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that
condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?

Choice A rationale:

Maintaining the client in the lithotomy position is not recommended during labor, particularly for extended periods.

It can impede blood flow, increase pressure on the sacral nerves, and potentially lead to discomfort, fatigue, and decreased

fetal oxygen supply.

It's essential to encourage position changes and ambulation during labor to promote comfort, fetal descent, and optimal blood

flow.

Choice B rationale:

Checking the client's temperature every 8 hours is not a priority intervention for a client in the active phase of labor following

an amniotomy.

While monitoring for infection is important, it's typically done more frequently, such as every 2-4 hours, if there are concerns

or risk factors.

More frequent temperature checks would be indicated if the client develops signs of infection, such as fever, chills, or foul-

smelling amniotic fluid.

Choice D rationale:

Reminding the client to bear down with each contraction is not appropriate during the active phase of labor.

Early bearing down can lead to maternal fatigue and potential complications like cervical lacerations, decreased fetal oxygen

supply, and perineal trauma.

It's generally recommended to encourage spontaneous pushing efforts when the client feels the urge to bear down, which

typically occurs during the second stage of labor when the cervix is fully dilated.

Choice C rationale:

Encouraging the client to empty the bladder every 2 hours is a crucial nursing intervention for a client in labor.

Here's why:

Preventing bladder distention: A full bladder can obstruct the fetal descent, prolong labor, and increase discomfort.

Promoting uterine contractions: An empty bladder allows more room for the uterus to contract effectively, facilitating labor

progress.

Reducing the risk of infection: Frequent bladder emptying helps prevent urinary tract infections, which can be more common

during labor due to catheterization or perineal trauma.

Enhancing comfort: A full bladder can cause significant pressure and discomfort for the laboring client. Emptying the bladder

regularly promotes relaxation and a sense of well-being.

Choice A rationale:

Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by

placing pressure on the perineum and reducing blood flow to the area.

Additionally, it can separate the buttocks, further straining the incision site and hindering healing.

It's crucial to prioritize interventions that promote circulation and reduce pressure on the perineum to facilitate healing and

pain management.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery.

Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying

healing.

It's essential to allow the initial inflammatory phase of wound healing to subside before introducing heat therapy.

Choice D rationale:

Preparing a warm sitz bath is a helpful intervention for episiotomy pain, but it's generally recommended after the first 24

hours.

During the initial phase of healing, warm water can increase blood flow to the area, potentially leading to increased swelling

and discomfort.

It's often more beneficial to focus on cooling measures within the first 24 hours to reduce inflammation and promote comfort.

Choice B rationale:

Applying an ice pack to the perineum is the most appropriate action for the nurse to take in this scenario.

Cold therapy effectively reduces inflammation, swelling, and pain by constricting blood vessels and slowing nerve conduction.

It's a non-invasive and readily available intervention that can significantly improve comfort and promote healing in the early

stages of episiotomy recovery.

Key points:

Ice packs are generally recommended for the first 24 hours following an episiotomy to reduce pain and inflammation.

Heat therapy, such as sitz baths or heating lamps, can be helpful after the initial 24-hour period to promote circulation and

healing.

Pillows or cushions under the buttocks should be avoided as they can increase pressure on the perineum and worsen pain.

Nurses play a crucial role in educating clients about episiotomy care and providing appropriate pain relief measures.