A nurse is providing care for a client who is in labor.
The nurse notes variable decelerations on the fetal heart rate monitor.
What could be the cause?

Choice A rationale:

Increasing fluid intake is not the priority action in this situation. While maintaining adequate hydration is important for

postpartum recovery, it does not directly address the immediate concern of excessive bleeding. Excessive fluid intake could

potentially worsen the bleeding by increasing blood volume and potentially increasing blood pressure.

Choice C rationale:

Helping the client use the bedpan to urinate is not the priority action in this case. While a full bladder can sometimes interfere

with uterine contraction and contribute to postpartum bleeding, it is not the most likely cause of the excessive bleeding in this

scenario. The client has already saturated two perineal pads in a short period, indicating a more significant bleeding issue that

needs to be addressed first.

Choice D rationale:

Preparing to administer tocolytic medication is not the appropriate action at this time. Tocolytic medications are used to stop

contractions, but they are not typically used to manage postpartum hemorrhage. In fact, tocolytics could potentially worsen

the bleeding by interfering with the natural mechanisms that help the uterus contract and stop bleeding after delivery.

Choice B rationale:

Checking the consistency of the client's uterine fundus is the priority action in this situation. The most common cause of

postpartum hemorrhage is uterine atony, which means the uterus is not contracting effectively to clamp down on the blood

vessels where the placenta was attached. A soft, boggy fundus is a sign of uterine atony. By assessing the fundus, the nurse can

quickly determine if uterine atony is the likely cause of the bleeding and take appropriate interventions to manage it.

Choice A rationale:

The location of the fundus is not a reliable indicator of urinary retention. The fundus may be displaced upward by a full

bladder, but it can also be displaced by other factors such as uterine atony or a full rectum.

In the early postpartum period, the fundus is expected to be firm and around 1-2 fingerbreadths below the umbilicus. A fundus

that is three fingerbreadths above the umbilicus may be a sign of uterine atony, but it is not specifically indicative of urinary

retention.

Choice B rationale:

Blood pressure is not a specific indicator of urinary retention. A blood pressure of 130/84 mm Hg is within the normal range

for a postpartum client.

Elevated blood pressure could be due to various factors, such as pain, anxiety, or pre-existing hypertension. It is not a reliable

sign of urinary retention on its own.

Choice C rationale:

Lochia rubra is the normal postpartum discharge that consists of blood, mucus, and tissue debris. The amount of lochia rubra

is expected to decrease gradually over time. Moderate lochia rubra is a normal finding in a client who is 8 hours postpartum

and does not suggest urinary retention.

Choice D rationale:

Moderate swelling of the labia is a common finding in the postpartum period due to increased blood flow and fluid retention.

However, significant swelling of the labia can also be a sign of urinary retention.

When the bladder is full, it can press on the surrounding tissues, including the labia, causing them to swell. If the client is also

experiencing difficulty voiding or has a decreased urine output, the swelling of the labia may be a sign that she needs to

urinate.