A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery.
Which of the following actions should the nurse take?

Choice A rationale:

Gestational hypertension is a condition characterized by elevated blood pressure during pregnancy. While it can increase the

risk of certain complications, it is not directly associated with an increased risk of postpartum hemorrhage. This is because

gestational hypertension primarily affects the vascular system, not the uterine muscle function, which is responsible for

controlling postpartum bleeding.

Choice B rationale:

A small for gestational age newborn (SGA) is a baby who is smaller than expected for their gestational age. While SGA can be

associated with some pregnancy complications, it is not a direct risk factor for postpartum hemorrhage. The size of the baby

does not have a significant impact on the ability of the uterus to contract and prevent excessive bleeding after delivery.

Choice C rationale:

Precipitous birth is defined as a labor that progresses very rapidly, with delivery occurring within three hours or less of the

onset of regular contractions. This rapid progression of labor can lead to postpartum hemorrhage for several reasons:

Uterine atony: The uterus may not have enough time to contract effectively after a rapid delivery, leading to increased

bleeding.

Lacerations and trauma: The rapid passage of the baby through the birth canal can increase the risk of tearing of the cervix,

vagina, or perineum, which can contribute to blood loss.

Retained placenta: The placenta may not separate from the uterine wall as easily after a precipitous birth, increasing the risk

of hemorrhage.

Choice D rationale:

A two-vessel umbilical cord is a variation in which the umbilical cord contains only two blood vessels (one vein and one

artery) instead of the usual three (one vein and two arteries). While this can be associated with certain fetal anomalies, it is not

a direct risk factor for postpartum hemorrhage. The number of blood vessels in the umbilical cord does not significantly

impact the ability of the uterus to contract and prevent bleeding after delivery.

Choice A rationale:

Amniotic fluid in the vaginal vault may indicate that the client's membranes have ruptured, but it does not necessarily mean

that labor has begun. Some women experience rupture of membranes before labor starts, while others do not experience it

until labor is well underway.

Additionally, it is not always possible to visually confirm the presence of amniotic fluid, as it may be mixed with other fluids or

present in small amounts.

Therefore, the presence of amniotic fluid alone is not a definitive sign of labor.

Choice B rationale:

Contractions are a common sign of labor, but they can also occur for other reasons, such as Braxton Hicks contractions or a

urinary tract infection.

To be considered a sign of true labor, contractions should be regular, becoming progressively stronger, longer, and closer

together.

A frequency of every 3 to 4 minutes is often suggestive of labor, but it is not always definitive.

Some women may experience contractions that are less frequent or more irregular and still be in labor.

Choice C rationale:

Cervical dilation is the most reliable sign of labor.

During labor, the cervix gradually opens to allow the baby to pass through the birth canal.

Cervical dilation is typically measured in centimeters, with 10 centimeters being considered full dilation.

Once the cervix has dilated to 3-4 centimeters, it is generally considered to be active labor.

This is because dilation of this degree usually indicates that the contractions are strong enough to effectively move the baby

through the birth canal.

Choice D rationale:

Pain just above the navel, also known as suprapubic pain, can be a sign of labor, but it is not a definitive one.

This type of pain can also be caused by other factors, such as bladder fullness or indigestion.

Additionally, not all women experience pain in this area during labor.