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:

Gestational hypertension is a condition characterized by elevated blood pressure during pregnancy. While it can increase the

risk of certain complications, it is not directly associated with an increased risk of postpartum hemorrhage. This is because

gestational hypertension primarily affects the vascular system, not the uterine muscle function, which is responsible for

controlling postpartum bleeding.

Choice B rationale:

A small for gestational age newborn (SGA) is a baby who is smaller than expected for their gestational age. While SGA can be

associated with some pregnancy complications, it is not a direct risk factor for postpartum hemorrhage. The size of the baby

does not have a significant impact on the ability of the uterus to contract and prevent excessive bleeding after delivery.

Choice C rationale:

Precipitous birth is defined as a labor that progresses very rapidly, with delivery occurring within three hours or less of the

onset of regular contractions. This rapid progression of labor can lead to postpartum hemorrhage for several reasons:

Uterine atony: The uterus may not have enough time to contract effectively after a rapid delivery, leading to increased

bleeding.

Lacerations and trauma: The rapid passage of the baby through the birth canal can increase the risk of tearing of the cervix,

vagina, or perineum, which can contribute to blood loss.

Retained placenta: The placenta may not separate from the uterine wall as easily after a precipitous birth, increasing the risk

of hemorrhage.

Choice D rationale:

A two-vessel umbilical cord is a variation in which the umbilical cord contains only two blood vessels (one vein and one

artery) instead of the usual three (one vein and two arteries). While this can be associated with certain fetal anomalies, it is not

a direct risk factor for postpartum hemorrhage. The number of blood vessels in the umbilical cord does not significantly

impact the ability of the uterus to contract and prevent bleeding after delivery.

Choice A rationale:

Retraction of the fetal head against the maternal perineum is a classic sign that the shoulders are about to be delivered. This is

known as the "turtle sign" because the fetal head appears to retract back into the body like a turtle's head.

It is important for the nurse to be prepared to assist with the delivery of the shoulders to ensure a safe and smooth delivery.

This includes:

Positioning the mother appropriately, such as in the McRoberts maneuver or a hands-and-knees position.

Applying gentle downward traction on the fetal head to help deliver the anterior shoulder.

Rotating the fetal shoulders as needed to facilitate delivery.

Monitoring the fetal heart rate closely for any signs of distress.

Choice B rationale:

While encouraging the mother to rest between contractions is important for conserving energy, it is not the priority action

when the fetal head is retracting. The nurse's focus should be on preparing for the delivery of the shoulders.

Choice C rationale:

Checking the mother's blood pressure is a routine part of labor and delivery care, but it is not specifically indicated when the

fetal head is retracting. There is no evidence to suggest that retraction of the fetal head is associated with changes in maternal

blood pressure.

Choice D rationale:

Administering oxygen to the mother may be helpful in some cases, such as if the fetal heart rate is showing signs of distress.

However, it is not the priority action when the fetal head is retracting. The focus should be on preparing for the delivery of the

shoulders.