A nurse is caring for a client who is 1 hour postpartum following a vaginal birth.
The client has saturated a perineal pad within 10 minutes.
Which of the following actions should the nurse take first?

Choice A rationale

Spontaneous rupture of membranes (SROM) can sometimes be associated with variable decelerations due to potential cord compression if the presenting part is not well applied, but it is not the most likely cause of early decelerations. Early decelerations reflect a physiological response to fetal head compression.

Choice B rationale

Fetal head compression during a contraction leads to vagal nerve stimulation, causing a transient decrease in the fetal heart rate. This deceleration is typically gradual in onset and recovery, mirroring the contraction pattern, and is considered a benign finding.

Choice C rationale

Umbilical cord compression typically results in variable decelerations, which are abrupt decreases in FHR that are not necessarily associated with uterine contractions. The shape and timing of variable decelerations differ significantly from the gradual, consistent pattern of early decelerations.

Choice D rationale

Utero-placental insufficiency usually manifests as late decelerations, which are gradual decreases in FHR that begin after the peak of the contraction and recover after the contraction ends. This pattern indicates fetal hypoxia and is a concerning finding, distinct from early decelerations.

Choice A rationale

Expressing milk when bottle-feeding can stimulate further milk production, which would exacerbate the engorgement and discomfort. The goal is to discourage milk production.

Choice B rationale

While a supportive bra is generally recommended for comfort, a loose-fitting bra might not provide adequate support to reduce swelling and discomfort associated with engorgement. A firm, supportive bra is usually advised.

Choice C rationale

Cold packs cause vasoconstriction, which helps to reduce blood flow to the breasts, thereby decreasing swelling, inflammation, and pain associated with engorgement. This provides symptomatic relief without stimulating milk production.

Choice D rationale

Warm water can stimulate milk flow, which is counterproductive when trying to suppress lactation in a bottle-feeding mother experiencing engorgement. Warmth increases blood flow and can worsen swelling and discomfort.