A nurse is assisting with the monitoring of a client who is in labor.
Which of the following findings should the nurse report to the provider?

Choice A rationale:

Performing hand hygiene before and after voiding is crucial in preventing perineal infection. Hand hygiene is the most

effective way to prevent the spread of infections, including those that can infect the perineum.

Choice B rationale:

Cleaning the perineal area from front to back is a standard recommendation to prevent infection. This method ensures that

bacteria from the anal area are not spread to the vagina and urethra, which can cause urinary tract infections.

Choice C rationale:

Sitting on an inflatable donut is not typically recommended for the prevention of perineal infection. While it can provide

comfort for those with perineal pain, especially after childbirth, it does not directly contribute to the prevention of infection.

Choice D rationale:

Applying ice packs to the perineal area several times daily can help reduce swelling and provide pain relief, especially after a

vaginal birth. While it does not directly prevent infection, it can promote healing and comfort, which can indirectly help

prevent infection.

Choice E rationale:

Blotting the perineal area dry after voiding is another important step in preventing perineal infection. Keeping the area dry

prevents the growth of bacteria and other microbes that thrive in moist environments.

Choice A rationale:

Maintaining the client in the lithotomy position is not recommended during labor, particularly for extended periods.

It can impede blood flow, increase pressure on the sacral nerves, and potentially lead to discomfort, fatigue, and decreased

fetal oxygen supply.

It's essential to encourage position changes and ambulation during labor to promote comfort, fetal descent, and optimal blood

flow.

Choice B rationale:

Checking the client's temperature every 8 hours is not a priority intervention for a client in the active phase of labor following

an amniotomy.

While monitoring for infection is important, it's typically done more frequently, such as every 2-4 hours, if there are concerns

or risk factors.

More frequent temperature checks would be indicated if the client develops signs of infection, such as fever, chills, or foul-

smelling amniotic fluid.

Choice D rationale:

Reminding the client to bear down with each contraction is not appropriate during the active phase of labor.

Early bearing down can lead to maternal fatigue and potential complications like cervical lacerations, decreased fetal oxygen

supply, and perineal trauma.

It's generally recommended to encourage spontaneous pushing efforts when the client feels the urge to bear down, which

typically occurs during the second stage of labor when the cervix is fully dilated.

Choice C rationale:

Encouraging the client to empty the bladder every 2 hours is a crucial nursing intervention for a client in labor.

Here's why:

Preventing bladder distention: A full bladder can obstruct the fetal descent, prolong labor, and increase discomfort.

Promoting uterine contractions: An empty bladder allows more room for the uterus to contract effectively, facilitating labor

progress.

Reducing the risk of infection: Frequent bladder emptying helps prevent urinary tract infections, which can be more common

during labor due to catheterization or perineal trauma.

Enhancing comfort: A full bladder can cause significant pressure and discomfort for the laboring client. Emptying the bladder

regularly promotes relaxation and a sense of well-being.