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:

Contraction duration: Contractions that last longer than 75 seconds are considered abnormal and should be reported to the

provider. This is because prolonged contractions can decrease oxygen supply to the fetus, leading to fetal distress.

Risk of uterine rupture: Excessively long contractions can also increase the risk of uterine rupture, a serious complication that

can endanger both the mother and the fetus.

Signs of fetal distress: The nurse should closely monitor the fetal heart rate for any signs of distress, such as late decelerations,

decreased variability, or bradycardia.

Need for intervention: If the contractions remain prolonged or if fetal distress is detected, the provider may need to intervene

to ensure the safety of both the mother and the fetus. This could involve measures such as administering medications to stop

or slow down labor, or performing a cesarean delivery.

Choice B rationale:

Contraction resting period: A contraction resting period of 35 seconds is within the normal range. Ideally, the resting period

between contractions should be at least 60 seconds, but it can vary. However, a resting period shorter than 30 seconds could

be a sign of tachysystole (excessively frequent contractions), which may also require intervention.

Choice C rationale:

Maternal heart rate: A maternal heart rate of 100 beats per minute is considered normal during labor. Heart rate can increase

with exertion, pain, and anxiety, which are common during labor. However, it's important to monitor for significant

tachycardia (heart rate over 120 beats per minute), which could indicate underlying issues such as dehydration or infection.

Choice D rationale:

Contraction frequency: One contraction in a 10-minute period is not indicative of active labor. Labor is typically defined as

having regular contractions that are 5 minutes apart or less, lasting for 45-60 seconds each, and causing progressive cervical

change. In early labor, contractions may be more sporadic and less intense.

Rationale for Choice A: Increase IV fluid rate

While hypotension is a potential complication of epidural anesthesia, increasing the IV fluid rate is not the first-line

intervention in this scenario. While fluid resuscitation may be necessary in some cases, it has the potential to further decrease

the client's blood pressure and exacerbate the situation. Additionally, the cause of the hypotension is not yet fully determined,

and increasing fluids without addressing the underlying cause could mask or worsen the problem.

Rationale for Choice B: Place the client in a lateral position

Supine hypotension, a sudden drop in blood pressure upon assuming a supine position, is a common complication of epidural

anesthesia. This occurs due to aortocaval compression, where the enlarged uterus compresses the major blood vessels

supplying the lower body and returning blood to the heart. Placing the client in a lateral position, preferably tilted slightly to

the left, alleviates this compression, allowing blood to flow more freely and improving blood pressure. This intervention is

simple, non-invasive, and has the potential to quickly resolve the hypotension without further interventions.

Rationale for Choice C: Notify the provider

While notifying the provider is certainly warranted in this situation, it should not be the first action taken. The client's vital

signs indicate a potentially serious situation requiring immediate intervention. Delaying action while waiting for the provider

could have negative consequences for both the client and the fetus. Therefore, placing the client in a lateral position should be

the immediate priority followed by notifying the provider to discuss further management.

Rationale for Choice D: Elevate the legs

Elevating the legs is a standard intervention for managing orthostatic hypotension, which is characterized by dizziness or

lightheadedness upon standing. However, in this case, the client is already supine and experiencing supine hypotension, not

orthostatic hypotension. Elevating the legs would not address the aortocaval compression and may even worsen the venous

return, further decreasing blood pressure.

Additional Notes:

Other interventions that may be considered depending on the client's response and provider's assessment include

administering vasopressors to increase blood pressure and administering oxygen to improve fetal oxygenation.

Continuous monitoring of the client's vital signs and fetal heart rate is crucial to assess the effectiveness of interventions and

identify any further deterioration.

Prompt communication with the provider is essential to ensure timely and appropriate management of the situation.