A nurse is preparing to administer an opioid analgesic to a client who is in active labor.
Which of the following assessments should the nurse perform?

Choice A rationale

Uterine contractions every 15 minutes are characteristic of the latent phase of labor, not the active phase. In the active phase, contractions typically become stronger, more frequent, and more regular, occurring every 2 to 5 minutes, signifying progressive cervical dilation.

Choice B rationale

A fetal heart rate (FHR) baseline of 166/min with minimal variability is concerning. While a baseline up to 160/min is generally normal, 166/min is slightly elevated, and minimal variability (5 bpm or less) can indicate fetal hypoxia or acidosis, necessitating further assessment and intervention. Normal FHR baseline is 110-160 bpm.

Choice C rationale

Late decelerations in FHR are non-reassuring findings indicative of uteroplacental insufficiency, meaning inadequate oxygen transfer to the fetus. These decelerations suggest potential fetal distress and require immediate intervention and reporting to the provider, not an expected finding in active labor.

Choice D rationale

Contraction duration of 75 seconds is an expected finding in the active phase of labor. During this phase, contractions typically last 45 to 90 seconds. This duration contributes to effective cervical effacement and dilation, signifying adequate uterine activity for labor progression.

Choice A rationale

A perineal hematoma is a collection of blood in the connective tissue beneath the skin, often caused by trauma during childbirth. The reported findings of increasing perineal pain, pressure, purplish discoloration, and swelling are classic signs. The purplish hue indicates extravasated blood, and the swelling reflects the accumulation of fluid, which can exert significant pressure on surrounding tissues, leading to severe discomfort and a palpable mass.

Choice B rationale

Retained placental fragments typically manifest as persistent or excessive postpartum bleeding, often bright red, and can lead to uterine subinvolution and infection. While pain might be present due to uterine contractions, it would not typically present as a localized, purplish, swollen area on the perineum. This finding is not consistent with the pathophysiology of retained placental fragments, which primarily affects the uterus.

Choice C rationale

A laceration is a tear in the soft tissues of the perineum or vagina, resulting in bright red bleeding, pain, and sometimes a visible opening. While pain is present, a laceration would not typically present with a 4 cm purplish discoloration and significant swelling without active, bright red bleeding from the tear site itself. The described findings are more indicative of internal bleeding and tissue accumulation rather than an open wound.

Choice D rationale

Ecchymosis is a bruise, characterized by superficial extravasation of blood into the skin or mucous membranes, resulting in a purplish discoloration. While the purplish discoloration is consistent, ecchymosis alone typically does not involve the significant palpable swelling and increasing pressure described. The extent of swelling and pressure points to a deeper collection of blood, distinguishing it from simple superficial bruising.