A nurse is caring for a client who is 4 hours postpartum.

The nurse finds a small amount of lochia rubra on the client's perineal pad.

The fundus is midline and firm at the umbilicus.

Which of the following actions should the nurse take?

Choice A rationale

The Apgar score is a rapid assessment tool utilized at 1 and 5 minutes after birth to evaluate a newborn's physiological adjustment to extrauterine life. It assesses five critical parameters that reflect the newborn's cardiorespiratory and neurological status.

Choice B rationale

While there are five components in the Apgar score (Appearance, Pulse, Grimace, Activity, Respiration), each component can be scored 0, 1, or 2, not just 1 or 2. This scoring system allows for a more nuanced assessment of the newborn's condition.

Choice C rationale

It is not unexpected for a newborn to receive a score of 1 for color, especially at the 1-minute Apgar, as acrocyanosis (bluish discoloration of the hands and feet) is common due to immature peripheral circulation. This finding alone does not typically indicate significant distress.

Choice D rationale

Resuscitation interventions should be initiated based on the newborn's immediate clinical assessment, regardless of the Apgar score. If a newborn exhibits signs of distress, such as apnea or bradycardia, resuscitation should commence promptly without waiting for the 1-minute Apgar score.

Choice A rationale

Repositioning the client to a left lateral position aims to improve uteroplacental perfusion by alleviating compression of the inferior vena cava by the gravid uterus. This enhances venous return to the mother's heart, increasing cardiac output and ultimately improving blood flow and oxygen delivery to the placenta and fetus, which can resolve late decelerations caused by uteroplacental insufficiency.

Choice B rationale

Documenting findings is a crucial nursing responsibility, but it is not the immediate intervention for addressing late decelerations. Scientific principles dictate that physiological stabilization takes precedence over documentation when fetal well-being is compromised. Documentation would follow after initial interventions are implemented to improve the fetal status.

Choice C rationale

Adjusting fetal monitor sensors might be necessary if the tracing is poor quality, but it does not directly address the physiological cause of late decelerations. Late decelerations reflect uteroplacental insufficiency, not merely a monitoring artifact. Addressing the underlying physiological compromise is the priority before troubleshooting equipment.

Choice D rationale

Inserting a fetal scalp electrode provides a more accurate assessment of fetal heart rate by directly monitoring the fetus. However, this is an invasive procedure and is typically considered after initial conservative measures, such as maternal repositioning and oxygen administration, have been attempted without resolution of the late decelerations.