An 18-year-old male patient arrives at the emergency department.

He has a cast to his lower leg.

He explains that he is in severe pain unrelieved by analgesics, paresthesia in his toes, and the nurse notes decreased capillary refill.

What is the most appropriate initial nursing intervention for this patient?

The nurse should determine that the FHR pattern represents Early decelerations due to Fetal head compression during contractions.

Rationale for correct answers:

Early decelerations are a gradual decrease and return to baseline of the fetal heart rate (FHR) associated with uterine contractions. They mirror contractions, beginning and ending with the contraction. This pattern is physiologic and typically benign.

Fetal head compression during contractions causes a vagal response leading to early decelerations. At a station of +4 and full dilation, fetal descent is significant, making head compression the most likely cause.

Rationale for incorrect Response 1 Options:

Late decelerations occur after the peak of the contraction and are due to uteroplacental insufficiency. These are non-reassuring and do not mirror contractions, unlike what is noted in the case.

Variable decelerations are abrupt drops in FHR and vary in timing, shape, and duration. They are not mirror images and are often associated with cord compression, which is not supported by this case’s findings.

Prolonged decelerations last >2 minutes and <10 minutes. The decelerations in this case are transient (to 105 bpm) and resolve before the end of the contractions, ruling out prolonged patterns.

Rationale for incorrect Response 2 Options:

Umbilical cord compression leads to variable decelerations, which are abrupt and not aligned with contraction timing, unlike the current pattern.

Uteroplacental insufficiency results in late decelerations, which occur after the contraction ends. These are non-reassuring and not consistent with the current findings.

Maternal hypotension due to epidural could cause late decelerations from reduced placental perfusion. However, despite a BP drop at 0900 (100/52 mm Hg), the FHR deceleration pattern does not match.

Take home points:

• Early decelerations are benign and typically reflect fetal head compression during contractions.
• Differentiate early from late decelerations based on timing relative to contractions—early mirrors, late lags.
• Variable decelerations are abrupt and typically linked to umbilical cord compression, not head compression.
• Maternal hypotension from epidural requires close monitoring, but it leads to uteroplacental insufficiency and late decelerations, not early.

Choice A rationale

A fundus that is deviated to the right, boggy, and 2 cm above the umbilicus suggests a distended bladder is displacing the uterus, preventing it from contracting effectively. A full bladder inhibits uterine involution by impeding the muscle fibers from compressing blood vessels, leading to uterine atony and increasing the risk of postpartum hemorrhage. Normal bladder capacity is 300-500 mL.

Choice B rationale

Obtaining a stat hemoglobin level is not the immediate priority. While a boggy uterus can indicate blood loss, the primary issue here is likely bladder distension causing uterine atony. Addressing the cause of the uterine displacement (bladder distension) takes precedence over assessing the degree of blood loss, which would be a secondary consequence. A normal hemoglobin for a woman is typically 12.0 to 15.5 grams per deciliter.

Choice C rationale

Administering methylergometrine is not the first action. Methylergometrine is a uterotonic agent used to promote uterine contractions and prevent postpartum hemorrhage. However, if the uterus is displaced by a full bladder, the medication's effectiveness will be significantly reduced until the bladder is emptied. Treating the underlying cause is crucial before administering uterotonics.

Choice D rationale

Inserting an indwelling urinary catheter is a more invasive intervention than assisting the client to void. While a catheter might be necessary if the client cannot void independently, the initial and least invasive action should always be to encourage spontaneous urination. Catheterization carries risks of urinary tract infection and discomfort, so it's not the first-line intervention.