A nurse is assisting with the admission of a client to the labor and delivery unit.

Exhibits

Which of the following actions should the nurse recommend including in the client's plan of care? For each potential recommendation, click to specify if the recommendation is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Rationale for Correct Options:

• Urge to defecate occurs as the fetal head descends further into the birth canal, putting pressure on the rectum and perineum. This is a common sign of the second stage of labor, indicating that the client is nearing delivery.
• Increased bloody show results from cervical dilation and effacement as the capillaries in the cervix rupture. A greater amount of blood-tinged mucus is expected as labor progresses, particularly in the transition phase and early second stage.
• Cervix 10 cm dilated confirms that the client has reached full cervical dilation, which is required for the second stage of labor to begin. Complete dilation allows for the passage of the fetus through the birth canal.
• Contractions strong on palpation indicate effective uterine activity, which is necessary for fetal descent and expulsion. Strong contractions help in moving the baby downward and increasing pressure on the cervix.

Rationale for Incorrect Options:

• A heart rate of 110/min is elevated compared to the client’s earlier readings (90/min at 0830, 110/min at 0845) and may indicate maternal stress or exertion from labor pain. While mild increases in maternal heart rate are expected during labor, tachycardia above 110/min warrants further evaluation, particularly in the presence of fever.
• Temperature of 39.1°C (102.4°F). This temperature is abnormally high and suggests infection, such as chorioamnionitis, especially considering the prolonged rupture of membranes since 1900 the previous night. Normal maternal temperature may rise slightly during labor due to exertion, but fever above 38°C (100.4°F) is concerning and requires medical attention.

A. "Occasional small clots in the urine." Small clots in the urine can be expected in the first 24 to 48 hours following a vaginal hysterectomy due to minor bleeding from surgical manipulation. However, large or persistent clots should be reported as they may indicate active bleeding.
B. "Frequent urge to urinate." A frequent urge to urinate is common after surgery due to bladder irritation, inflammation, or the effects of anesthesia. However, if accompanied by pain, burning, or difficulty urinating, it could indicate a urinary tract infection or urinary retention requiring further evaluation.
C. "Dark red urine." Dark red urine suggests active bleeding, which is not an expected postoperative finding and requires immediate evaluation. This may indicate excessive surgical site bleeding or trauma to the urinary tract, necessitating prompt intervention by the provider.
D. "Urine output of 300 mL over 8 hr." While this is lower than the expected urine output (at least 30 mL/hr or 240 mL in 8 hours), it is not critically low. The nurse should encourage fluid intake and monitor for signs of dehydration or urinary retention before escalating the concern to the provider.