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:

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.

Choice A rationale:

Encouraging the mother to push during the next contraction is not the appropriate action in this situation. Retraction of the

fetal head against the maternal perineum is a sign of shoulder dystocia, a serious obstetric emergency that requires immediate

intervention. Pushing could potentially worsen the situation by further impacting the anterior shoulder against the maternal

pubic symphysis.

Choice B rationale:

While preparing for immediate delivery of the baby may be necessary in some cases of shoulder dystocia, it is not the first

priority. The initial focus should be on relieving the impaction of the anterior shoulder and facilitating the safe delivery of the

baby. This often requires additional maneuvers and medical support.

Choice C rationale:

Calling for additional medical support is the most appropriate action in this situation. Shoulder dystocia can be a complex and

challenging emergency, and it's crucial to have experienced healthcare providers available to assist with the delivery.

Additional personnel can provide support with various maneuvers, fetal monitoring, and management of potential

complications.

Choice D rationale:

Administering pain relief medication is not a priority in this situation. While pain management is important during labor, it

should not take precedence over addressing the immediate obstetric emergency. The focus should be on resolving the

shoulder dystocia and ensuring a safe delivery.

Additional notes:

It's important to note that shoulder dystocia is a relatively uncommon complication, occurring in approximately 0.5-1% of all

vaginal births. However, it's a potentially serious emergency that can lead to significant complications for both the mother and

baby, such as brachial plexus injury, hypoxic-ischemic encephalopathy, and postpartum hemorrhage.

Early recognition and prompt intervention are crucial for optimizing outcomes in cases of shoulder dystocia.