A nurse is assisting with the care of a client who is at 7 cm of cervical dilation and 100% effacement, and in active
labor.
The client informs the nurse that she needs to push.
Which of the following is the appropriate action for the nurse to take?

Choice A rationale:

Elevating the client's legs can improve venous return and cardiac output, but it does not directly address the underlying cause

of late decelerations, which is uteroplacental insufficiency.

While elevating the legs may have some benefit, it's not the most effective initial action to address late decelerations.

It's important to prioritize interventions that directly improve uteroplacental blood flow.

Choice C rationale:

Increasing the infusion rate of IV fluids can expand maternal blood volume, but it may not significantly improve uteroplacental

perfusion if there's underlying placental insufficiency.

It's not the most effective initial action to address late decelerations.

It may be considered as a secondary measure if repositioning doesn't resolve the decelerations.

Choice D rationale:

Administering oxygen via face mask can improve fetal oxygenation, but it does not directly address the underlying cause of

late decelerations, which is uteroplacental insufficiency.

It's not the most effective initial action to address late decelerations.

It may be considered as an adjunct measure to improve fetal oxygenation, but it's not a primary intervention for late

decelerations.

Choice B rationale:

Positioning the client on her side is the most effective initial action to address late decelerations because it:

Relieves pressure on the vena cava, which improves venous return and cardiac output.

Increases placental perfusion by increasing blood flow to the uterus.

This can help to correct fetal hypoxia and improve fetal heart rate patterns.

It's a simple, non-invasive intervention that can be quickly implemented and has a high success rate in resolving late

decelerations.

Choice A rationale:

Fever: A hallmark sign of inflammation, fever is a common and often early manifestation of endometritis. The body's

thermostat, located in the hypothalamus, is reset to a higher temperature in response to infection or inflammation. This

triggers a cascade of physiological events, including chills, shivering, and increased heat production, as the body attempts to

fight off pathogens. In endometritis, the fever is typically 100.4°F (38°C) or higher.

Chills: Often accompanying fever, chills are a sensation of coldness despite a normal or elevated body temperature. They result

from involuntary muscle contractions, which generate heat in an attempt to raise the body's temperature. Chills can be mild or

severe, and they often precede a rise in temperature.

Choice B rationale:

Increased heart rate: Tachycardia, or an increased heart rate, can occur in endometritis, but it is not a specific finding. It can be

present in various other conditions, including anxiety, pain, dehydration, anemia, and other infections. While it may be a sign

of endometritis, it's not considered a primary manifestation.

Choice C rationale:

Lower abdominal pain: Lower abdominal pain is a common symptom in postpartum women, but it is not always indicative of

endometritis. It can result from uterine contractions, incisional pain (if a cesarean section was performed), bladder distention,

constipation, or other postpartum complications. While it may be present in endometritis, it's not a specific finding.

Choice D rationale:

Unusual vaginal discharge: Lochia, the normal postpartum vaginal discharge, can vary in color and amount. However, unusual

vaginal discharge, such as foul-smelling or purulent discharge, can be a sign of endometritis. It's important to note that not all

women with endometritis will have abnormal discharge.