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:

While some of the client's findings are consistent with normal labor progression, the decelerations in the fetal heart rate (FHR) are concerning and indicate a potential problem. Normal labor progression would not typically involve FHR decelerations.

Choice B rationale:

Monitoring contractions and fetal heart rate: This is crucial to assess the client's labor progress and fetal well-being. The frequency, duration, and intensity of contractions, as well as the baseline FHR, variability, and presence of any decelerations, should be closely monitored. These parameters provide essential information about the adequacy of uterine contractions, fetal oxygenation, and potential need for interventions.

Choice C rationale:

Ensuring the client is comfortable and hydrated: Comfort measures can help the client cope with labor pain and anxiety, which can indirectly improve fetal oxygenation by reducing stress hormones. Hydration is essential for maintaining adequate blood flow to the placenta and fetus, supporting fetal well-being.

Choice D rationale:

While monitoring pain level and fluid intake is important, they are not the most immediate priorities in this situation. The priority is to address the potential fetal distress indicated by the FHR decelerations and ensure adequate uterine contractions and fetal oxygenation.

Additional notes:

The nurse should also notify the healthcare provider of the FHR decelerations and any other concerning findings.

Further interventions, such as changing the client's position, administering oxygen, or discontinuing the oxytocin infusion, may be necessary depending on the assessment findings and provider's orders.

The correct answer is Choice A

Choice A rationale: A distended bladder can displace the uterus upward and to the side, preventing proper uterine involution and increasing risk of postpartum hemorrhage.

Choice B rationale: Blood pressure of 130/84 mm Hg is within normal postpartum range and does not indicate urinary retention or bladder distention.

Choice C rationale: Moderate lochia rubra is expected postpartum and reflects normal uterine shedding, not urinary status.

Choice D rationale: Moderate labial swelling may occur from delivery trauma but does not directly indicate bladder fullness or urinary retention.