A nurse is caring for a client who is 2 hours postpartum.
The client has an IV infusion of lactated Ringer’s with 25 units of oxytocin and large lochia rubra.
Vital signs include blood pressure 146/81, pulse 80/min, and respirations 18/min.
Which of the following actions should the nurse clarify with the provider?

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.

Choice A rationale:

Fetal attitude in general flexion is not a contributing factor to difficult, prolonged labor. In fact, it is the normal fetal attitude

during labor. The fetus is typically in a position of general flexion, where the head is flexed forward, chin to chest, and the arms

and legs are flexed, with the arms crossed over the chest and the legs bent at the knees.

Choice B rationale:

Fetal lie being longitudinal is the normal and most common fetal lie during labor. In a longitudinal lie, the long axis of the fetus

is parallel with the long axis of the mother. This is the ideal and most common position for labor and delivery.

Choice C rationale:

A gynecoid pelvis is the most common type of female pelvis and is the most favorable for childbirth. It has a round shape with

a wide pubic arch, which allows for easier passage of the baby during delivery.

Choice D rationale:

A persistent occiput posterior (OP) position can indeed contribute to difficult, prolonged labor. In an OP position, the baby’s

occipital bone is towards the mother’s posterior side. This position can cause labor to be more painful and last longer because the baby’s head diameter that presents to the birth canal is larger. It can also cause back pain during labor, often referred to as "back labor"1.