The nurse is assessing a patient in Labor with the findings in the chart: Fatal heart rate 135 with early decelerations. What action will the nurse implement?

The correct order is: b, a, d, c

1. b) Position the patient in a supine position: The first step is to ensure the patient is in a supine position, which is lying on their back. This position provides the best access and visibility for the nurse to assess the fundus effectively. Ensuring the patient is comfortable and relaxed in this position is crucial before beginning the assessment.
2. a) Place one hand on the lower segment of the uterus: The next step involves placing one hand on the lower segment of the uterus. This helps to stabilize the uterus and provides support while the nurse palpates the fundus. It also prevents any excessive movement that could cause discomfort or complications.
3. d) Press at the level of the umbilicus to palpate the fundus: The nurse then presses at the level of the umbilicus (belly button) to palpate the fundus. The fundus is the top portion of the uterus, and assessing its position and firmness provides important information about the postpartum recovery process.
4. c) Gently massage the fundus in a circular motion: Finally, the nurse gently massages the fundus in a circular motion. This action helps to ensure the uterus remains firm and can help in preventing postpartum haemorrhage. If the fundus is not firm, the massage can stimulate uterine contractions to firm it up.

Choice A reason: Calling the healthcare provider is a valid action if the nurse encounters an unexpected issue or an emergency. However, in this situation, the nurse's immediate observation of physical signs indicating pain suggests that the patient might be experiencing discomfort. The nurse has enough clinical judgment to address the pain directly rather than waiting for a healthcare provider's intervention, which could delay relief.

Choice B reason: Waiting for the patient to report pain is not an ideal choice here because children, especially younger ones, may not always verbalize their pain even when they are in discomfort. The nurse's role involves assessing both verbal and non-verbal cues to provide timely and appropriate care. Physical signs such as clenched fists and a wrinkled forehead strongly indicate pain, necessitating prompt action rather than waiting.

Choice C reason: Administering intravenous morphine is the appropriate intervention given the clear physical signs of pain observed by the nurse. Morphine is a powerful opioid analgesic used to manage moderate to severe pain. In a post-surgical context, controlling pain effectively is crucial for the patient's recovery. Therefore, this action aligns with the need for timely pain management to ensure the child's comfort and facilitate healing.

Choice D reason: Instructing the parent to play relaxing music can be a helpful non-pharmacological intervention to provide a calming environment for the child. However, this action alone is unlikely to address the acute pain suggested by the patient's physical signs. While it can be part of a comprehensive pain management plan, the primary approach should be administering medication to relieve the immediate pain.