A nurse is assisting with the care of a client who is in labor and has the urge to push.
Which of the following instructions should the nurse give the client?

Choice A rationale:

The client is in the second stage of labor because she is actively pushing and the fetal head is at the vaginal station.

The second stage of labor is defined as the time from full cervical dilation to the birth of the baby. It is characterized by strong,

regular contractions and the urge to push.

Decelerations in the fetal heart rate can occur during the second stage of labor due to a variety of factors, including head

compression, cord compression, and uteroplacental insufficiency.

Choice B rationale:

The nurse should apply an oxygen mask to the client to increase the oxygen supply to the fetus.

This can help to improve fetal heart rate and prevent further decelerations.

Oxygen is a vital nutrient for the fetus, and it is essential for maintaining a normal fetal heart rate.

When the fetal heart rate decelerates, it is a sign that the fetus is not getting enough oxygen.

Applying an oxygen mask to the mother can help to increase the amount of oxygen that is available to the fetus.

Choice D rationale:

The nurse should monitor the client's vital signs and fetal heart rate to assess the client's progress and the well-being of the

fetus.

Vital signs, such as blood pressure, pulse, and respiration rate, can provide important information about the mother's health

and how she is coping with labor.

The fetal heart rate is a direct measure of the fetus's well-being.

By monitoring these parameters, the nurse can identify any potential problems and intervene as needed.

Additional notes:

The nurse should also encourage the client to change positions, as this can help to relieve cord compression.

The nurse should also prepare for the possibility of a rapid delivery, as decelerations in the fetal heart rate can sometimes be a

sign of fetal distress.

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.