A nurse is assisting in the care of a client who is at 38 weeks of gestation.
What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that
condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?

Choice A rationale:

While some of the client's findings are consistent with normal labor progression, the decelerations in the fetal heart rate (FHR) are concerning and indicate a potential problem. Normal labor progression would not typically involve FHR decelerations.

Choice B rationale:

Monitoring contractions and fetal heart rate: This is crucial to assess the client's labor progress and fetal well-being. The frequency, duration, and intensity of contractions, as well as the baseline FHR, variability, and presence of any decelerations, should be closely monitored. These parameters provide essential information about the adequacy of uterine contractions, fetal oxygenation, and potential need for interventions.

Choice C rationale:

Ensuring the client is comfortable and hydrated: Comfort measures can help the client cope with labor pain and anxiety, which can indirectly improve fetal oxygenation by reducing stress hormones. Hydration is essential for maintaining adequate blood flow to the placenta and fetus, supporting fetal well-being.

Choice D rationale:

While monitoring pain level and fluid intake is important, they are not the most immediate priorities in this situation. The priority is to address the potential fetal distress indicated by the FHR decelerations and ensure adequate uterine contractions and fetal oxygenation.

Additional notes:

The nurse should also notify the healthcare provider of the FHR decelerations and any other concerning findings.

Further interventions, such as changing the client's position, administering oxygen, or discontinuing the oxytocin infusion, may be necessary depending on the assessment findings and provider's orders.

Choice A rationale:

The fundus at the umbilicus level is a normal finding in the immediate postpartum period. After delivery, the top of the uterus

(known as the fundus) is typically at the level of the umbilicus. In the days following delivery, the uterus begins to shrink and

descend into the pelvic cavity, guided by the process known as involution.

Choice B rationale:

A urinary output of 3,000 mL is unusually high and could indicate a postpartum complication. Postpartum diuresis is common

as the body eliminates excess fluid accumulated during pregnancy. However, excessive urinary output could be a sign of

postpartum complications such as postpartum preeclampsia, which can occur after the birth of the baby and is characterized

by high blood pressure and signs of damage to another organ system, often the kidneys.

Choice C rationale:

A temperature of 100.4 F for two days postpartum can be a normal finding. It’s not uncommon for women to experience a

slight elevation in temperature in the first 24 hours after delivery due to the exertion of labor. However, a temperature above100.4 F beyond the first 24 hours could indicate an infection and should be evaluated.

Choice D rationale:
A cesarean section shortly following delivery is not typically a sign of a postpartum complication. It’s a surgical procedure used to deliver the baby and can be planned or unplanned due to various reasons such as the baby’s position, multiple pregnancies, or complications during labor. However, like any surgery, a cesarean section does carry risks and can increase the likelihood of certain postpartum complications such as infection or blood clots.