A first-time mother presents for a labor check.
She is informed that her vaginal exam shows dilated (3 cm), effaced (100%), and fetal station (-2). What explanation is the most appropriate response by the nurse?

Choice A rationale

Assisting the patient onto her left side can improve uteroplacental perfusion by relieving pressure on the vena cava, potentially improving fetal oxygenation and addressing fetal heart rate decelerations. This position maximizes blood flow to the uterus and placenta.

Choice B rationale

A vaginal examination is crucial to assess for umbilical cord prolapse, especially in the presence of fetal heart rate decelerations or bradycardia. Prolapse of the cord can severely compromise fetal oxygen supply, necessitating immediate intervention.

Choice C rationale

Discontinuing the oxytocin infusion is essential if fetal heart rate abnormalities occur, as oxytocin stimulates uterine contractions, which can further compromise fetal oxygenation if the fetus is already stressed. Reducing or stopping contractions can alleviate fetal distress.

Choice D rationale

Administering oxygen at 10 L/min via nonrebreather face mask increases the maternal oxygen supply, which in turn can increase the oxygen available to the fetus across the placenta. This is a standard intervention for fetal distress.

Choice E rationale

Notifying the health care provider is a critical step to communicate the fetal heart rate abnormalities and the interventions implemented. The provider can then assess the situation, determine the underlying cause, and order further management.

Choice F rationale

Stopping the magnesium sulfate is indicated primarily for signs of magnesium toxicity in the mother, such as respiratory depression, loss of deep tendon reflexes, or decreased urine output. While magnesium sulfate can affect the fetus, it is not a first-line intervention for fetal heart rate abnormalities unless related to preterm labor management.

Choice A rationale

While support from family is beneficial, advising the client to solely rely on family for stress reduction and baby care without further assessment may delay the identification and treatment of a potential postpartum mood disorder. It's crucial to first understand the underlying cause of her feelings.

Choice B rationale

Encouraging rest is a general recommendation for postpartum recovery and fatigue. However, the client's report of anxiety, irritability, and feelings of inadequacy suggests more than just typical postpartum fatigue and warrants a more focused assessment for a mood disorder.

Choice C rationale

The client's symptoms of anxiety, irritability, inability to sleep despite fatigue, and feelings of inadequacy are indicative of a potential postpartum mood disorder, such as postpartum depression or anxiety. A thorough assessment using standardized screening tools and further questioning about the onset, duration, and severity of these symptoms is the most appropriate initial action to determine the need for further intervention and support.

Choice D rationale

While some emotional fluctuations are common in the immediate postpartum period ("baby blues"), the combination and intensity of the client's reported symptoms, particularly the feelings of inadequacy and persistent sleep disturbance despite fatigue, suggest a need for further evaluation rather than simply reassurance that these feelings are normal and transient. .