The nurse is evaluating the external fetal monitoring strip of a laboring client.
Based on the information from the strip, what is the nurse's next plan of action?

Neonatal resuscitation focuses on the transition to extrauterine life, emphasizing the ABCs. Nurses must apply knowledge of the Neonatal Resuscitation Program guidelines for a severely depressed infant. Prioritizing airway and ventilation is crucial for improving low Apgar scores.

Choice A rationale

Identification is a legal requirement for infant safety and security. However, in a resuscitation scenario with an Apgar score of 1, life-saving interventions like ventilation take immediate priority over administrative tasks such as applying identification bands.

Choice B rationale

Intravenous access allows for fluid volume expansion or medication delivery. While important for stabilization, it is secondary to establishing effective ventilation. Ventilation is the most critical step in improving heart rate and oxygenation in neonates.

Choice C rationale

An Apgar score of 1 indicates severe distress requiring immediate resuscitation. Preparing the bag and mask ensures that positive pressure ventilation can start immediately upon arrival. Establishing an airway and providing oxygen are the highest priorities.

Choice D rationale

Vitamin K and erythromycin are standard prophylactic treatments for newborns. These prevent bleeding and ophthalmia neonatorum, respectively. However, they are not urgent and should only be administered once the newborn is physiologically stable after resuscitation.

Managing postpartum breast engorgement in formula-feeding clients requires applying knowledge of lactation suppression. The nurse must identify interventions that reduce vascularity and inflammation without stimulating further milk production, focusing on comfort and the eventual cessation of the milk supply through physiological feedback.

Choice A rationale

Warm water stimulates vasodilation and let-down, which increases milk production and worsens engorgement for a non-breastfeeding client. Heat should be avoided to help the drying-up process. Cold is preferred to constrict vessels and reduce swelling.

Choice B rationale

Ice packs and cold cabbage leaves promote vasoconstriction and reduce edema and pain. For a formula-feeding mother, this intervention provides comfort without stimulating the nipples, helping to suppress lactation by reducing the metabolic activity of the glandular tissues.

Choice C rationale

Expressing milk, even in small amounts, signals the body to produce more milk via a positive feedback loop. This prevents the natural drying-up process and prolongs the discomfort of engorgement for a client who is not breastfeeding.

Choice D rationale

A loose-fitting bra allows for breast movement, which can stimulate the nipples and increase discomfort. A supportive, well-fitting, or firm bra is recommended to provide compression and minimize stimulation, which helps suppress the production of milk..