A nurse is assisting with the care of a client who is in the second stage of labor.
The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.



Which of the following actions should the nurse 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:

Normal progression of labor: After the fetal head is delivered, the shoulders typically follow immediately. The nurse should be prepared to assist with the delivery of the shoulders to ensure a safe and smooth birth process.

Significance of retraction: Retraction of the fetal head against the maternal perineum, also known as the "turtle sign," is a classic indicator of shoulder dystocia. While this sign does not guarantee shoulder dystocia, it warrants immediate preparation for potential management.

Anticipating shoulder dystocia: By anticipating the possibility of shoulder dystocia, the nurse can take proactive measures to minimize risks and facilitate delivery. These measures may include:

Positioning the mother appropriately (e.g., McRoberts maneuver)

• Applying suprapubic pressure
• Performing internal maneuvers (e.g., Rubin's maneuver)
• Breaking the clavicle (in extreme cases)

Choice B rationale:

Ineffective in shoulder dystocia: Encouraging the mother to push during the next contraction is not an effective intervention

for shoulder dystocia. In fact, excessive pushing can worsen the impaction of the shoulders and potentially lead to

complications such as fetal hypoxia, brachial plexus injury, or maternal perineal trauma.

Choice C rationale:

Necessary in confirmed dystocia: Calling for additional medical support is crucial if shoulder dystocia is confirmed. However,

immediate preparation for shoulder delivery should commence without delay, as prompt action is essential to prevent adverse

outcomes.

Choice D rationale:

Secondary concern: While pain relief medication may be administered for maternal comfort, it is not a priority intervention in

this situation. The primary focus should be on managing the potential shoulder dystocia and ensuring the safe delivery of the

baby.