A nurse is developing a plan of care for a client who is in the latent phase of labor.
Which of the following interventions should the nurse include in the plan to manage the client's pain?

Choice A rationale

The client's fundus is boggy and elevated above the umbilicus, deviating to the right, which indicates uterine atony. This, coupled with the saturated perineal pad and voiding of only 50 mL of urine initially, followed by 700 mL of pink-tinged urine after catheterization, suggests significant blood loss. These findings are classic signs of postpartum hemorrhage, which is often caused by uterine atony preventing effective uterine contraction and vessel compression. Normal postpartum fundal height should decrease daily.

Choice B rationale

Postpartum infection, such as puerperal sepsis, typically presents with fever, chills, uterine tenderness, and foul-smelling lochia. While the client is experiencing discomfort, there is no mention of fever or purulent discharge. The primary signs observed relate to excessive bleeding and uterine displacement, not infectious processes. A normal temperature range is 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice C rationale

Endometritis is an infection of the uterine lining, often occurring postpartum. Symptoms include fever, lower abdominal pain, uterine tenderness, and foul-smelling lochia. The client's symptoms of a boggy fundus, heavy bleeding, and fundal deviation are more indicative of a bleeding issue rather than an infection confined to the endometrium. White blood cell count would typically be elevated in infection, with a normal range being 4,500 to 11,000 cells/mm³.

Choice D rationale

A urinary tract infection (UTI) is characterized by dysuria, urgency, frequency, and sometimes hematuria. While the client reports an urge to urinate and voided a small amount, the primary and more concerning findings are related to the uterine status and excessive bleeding, which are not typical signs of a UTI. A urine culture would show bacterial growth in a UTI, with a normal urinalysis showing no or few bacteria.

Choice E rationale

Uterine inversion is a rare but severe complication where the uterus turns inside out, often presenting with sudden, severe pain, vaginal hemorrhage, and a mass protruding from the vagina. While hemorrhage is present, the description of the fundus being boggy and 2 finger breaths above the umbilicus, rather than inverted or prolapsed, makes uterine inversion less likely. The primary issue is uterine atony leading to blood loss.

Choice A rationale

During labor, the body experiences physiological stress and an inflammatory response, leading to an increase in white blood cell count. This leukocytosis is a normal physiological adaptation to the physical demands of labor and tissue remodeling, not a decrease. A normal WBC count is typically 4,500-11,000 cells/µL, and it can rise to 15,000-20,000 cells/µL during labor.

Choice B rationale

Labor is an energy-intensive process that increases metabolic demands, leading to greater glucose utilization by uterine muscles and other tissues. This increased consumption of glucose can result in a decrease in blood glucose levels as the body expends energy to fuel contractions and other physiological activities. A normal blood glucose range is 70-100 mg/dL.

Choice C rationale

The pain and physiological stress of labor typically cause an increase in respiratory rate, not a decrease. The body tries to compensate for the increased metabolic demand and oxygen consumption by increasing ventilation. A decrease in respiratory rate would be an unexpected and potentially concerning finding, indicating respiratory depression. A normal respiratory rate is 12-20 breaths per minute.

Choice D rationale

While slight fluctuations can occur, a significant decrease in temperature is not an expected finding during labor. The metabolic activity and physical exertion of labor can slightly elevate body temperature, or it may remain stable. A decrease in temperature could indicate hypothermia or a systemic issue, which is not a normal physiological response to labor. A normal temperature is 36.5-37.5°C.