A nurse on the labor and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?

Uterine rupture is a rare but life-threatening complication of labor and delivery that occurs when the uterus tears open along the scar line of a previous cesarean delivery or other uterine surgery¹². Uterine rupture can cause severe bleeding in the mother and deprive the baby of oxygen¹². Some of the signs and symptoms of uterine rupture are:
- Sudden, severe lower abdominal pain
- Drop in blood pressure
- Cool skin and pallor
- Prolonged fetal bradycardia (slow heart rate)
- Loss of fetal station (the baby moves back up the birth canal)
- Abnormal or absent uterine contractions¹²³

Uterine rupture is a medical emergency that requires immediate surgery to deliver the baby and repair the uterus or remove it (hysterectomy)¹².
The other options are incorrect because they have different signs and symptoms:
b) Amniotic fluid embolism is a rare but serious condition that occurs when amniotic fluid or fetal cells enter the mother's bloodstream and trigger an allergic reaction. It can cause sudden respiratory distress, cardiac arrest, seizures, or coma in the mother and fetal distress or death in the baby¹². It usually occurs during labor, delivery, or shortly after birth¹².
c) Placenta previa is a condition where the placenta covers part or all of the opening of the cervix. It can cause painless vaginal bleeding during pregnancy or labor¹². It does not affect the blood pressure or fetal heart rate unless there is severe bleeding or placental abruption (separation of the placenta from the uterine wall)¹².
d) Umbilical cord prolapse is a condition where the umbilical cord slips through the cervix and into the vagina before or during labor. It can cause fetal distress, as the cord can become compressed or twisted, cutting off the blood supply and oxygen to the baby¹². It usually causes a sudden drop in fetal heart rate, but does not affect the maternal blood pressure or cause abdominal pain¹².

This is the action that the nurse should take after recognizing an early deceleration of the fetal heart rate tracing. Early decelerations are symmetrical decreases and return-to-normal linked to uterine contractions¹. The decrease in heart rate occurs gradually, and the nadir of the deceleration occurs at the same time as the peak of the uterine contraction³. Early decelerations are caused by compression of the fetus's head during a uterine contraction, which can stimulate the vagus nerve and cause a decrease in the fetal heart rate⁴. Early decelerations are nothing to be alarmed about¹. They are considered normal and benign, as they do not affect fetal oxygenation or well-being³. Therefore, the nurse should continue to monitor the client and the fetal heart rate tracing and document the findings.

The other options are not correct because they are not appropriate actions for early decelerations.
a) Assist the client to lay on her right side.
This is not an appropriate action for early decelerations, as they are not caused by maternal position or uteroplacental insufficiency. Changing the maternal position may help improve fetal oxygenation and blood flow in cases of late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.
c) Discontinue the oxytocin.
This is not an appropriate action for early decelerations, as they are not caused by oxytocin administration or uterine hyperstimulation. Oxytocin is a hormone that stimulates uterine contractions and can be used to induce or augment labor. However, excessive or prolonged use of oxytocin can cause uterine fatigue and reduce its ability to contract after delivery, leading to uterine atony and postpartum hemorrhage². Oxytocin can also cause late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.

d) Administer oxygen at 8 L/min per mask.
This is not an appropriate action for early decelerations, as they are not caused by fetal hypoxia or acidosis. Oxygen administration may help improve fetal oxygenation and blood flow in cases of late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.