The nurse and student are discussing clients who are laboring on the unit.
Which clients would the nurse encourage to attempt a vaginal birth after having a cesarean section? Select all that apply.

Step 1 is: The standard initial management for postpartum hemorrhage (PPH) is fundal massage and the administration of the uterotonic drug oxytocin. Since the client's hemorrhage is unresponsive to these, a second-line uterotonic is required. Methylergonovine (Methergine) is a potent uterotonic that directly stimulates smooth muscle contraction.

Step 2 is: Methylergonovine is typically administered intramuscularly (IM) as a 0.2 mg dose. The IM route provides reliable absorption and rapid onset of action (2-5 minutes). The medication is contraindicated in clients with hypertension or preeclampsia due to its potent vasoconstrictive properties, which can cause dangerous blood pressure elevation.

Step 3 is: The nurse must check the client's blood pressure before administration, with a blood pressure of 140/90 mmHg or less often being a required threshold for safe use. The second most critical assessment is urine output (normal range is ≥ 30 mL/h) to assess for signs of hypovolemic shock or renal perfusion compromise, which are important considerations in active hemorrhage.

Step 4 is: Choice B states to administer methylergonovine 0.2 mg intramuscularly if her urine output is less than 50 mL/h. The IM dose and route are correct, but the rationale regarding urine output is incorrect; low urine output is a sign of worsening PPH and not a condition for administering methylergonovine. Choice B must be a typo in the question or options. Choice C offers the correct contraindication (BP below 140/90) for the IV route which is correct for severe hemorrhage although IM is more common. Choice B is the most plausible answer provided in the context of advanced PPH management despite the flaw in the rationale's condition, as it uses the correct dose and route.

Choice A rationale

The distribution of erectile tissue in the nipples primarily affects the ability to latch initially but is not a significant determinant of long-term breastfeeding success. Milk production and flow, which are driven by hormones like prolactin and oxytocin and are dependent on effective suckling, are the key physiological factors for sustaining breastfeeding, which are less reliant on erectile tissue.

Choice B rationale

The client's dietary intake of milk products during pregnancy has no direct, significant physiological or nutritional impact on the ability to produce breast milk post-delivery. Breast milk production relies on the mother's overall nutritional status and fluid intake, and the hormonal stimulation from the infant's suckling; specific dairy consumption is irrelevant to success.

Choice C rationale

The viewpoint of the client's family profoundly influences the success of breastfeeding by affecting the mother's stress levels, confidence, and access to practical support (e.g., emotional support, help with other children). Supportive partners and family members increase the mother's self-efficacy and her ability to manage challenges, which is critical for adherence and successful continuation of breastfeeding.

Choice D rationale

The age of the client at the time of delivery, whether adolescent or mature, has no direct physiological impact on the ability to produce breast milk. Milk production is a complex process primarily governed by endocrine changes (prolactin and oxytocin release) and the principle of supply and demand, which are independent of maternal age once the mammary glands are fully developed.