What is the priority nursing intervention for a patient experiencing umbilical cord prolapse during labor?

Choice A rationale

Methylergonovine is an oxytocic medication that stimulates smooth muscle contraction of the uterus. While it can cause vasoconstriction and potentially lead to an increase in blood pressure, this is a potential side effect, not the intended therapeutic effect indicating the medication's effectiveness in the postpartum period. The primary goal is uterine contraction to control postpartum bleeding.

Choice B rationale

Breast pain is related to engorgement and milk production, not directly influenced by methylergonovine's action on the uterus. The medication's effectiveness is assessed by its impact on uterine tone and bleeding, not breast comfort. Therefore, the absence of breast pain does not indicate that the methylergonovine has been effective.

Choice C rationale

Methylergonovine is given to decrease postpartum bleeding by promoting uterine contraction, which helps to compress the blood vessels at the placental site. An increase in lochia (postpartum vaginal discharge) would suggest that the medication is not effective in achieving its intended therapeutic outcome of reducing hemorrhage.

Choice D rationale

Methylergonovine's primary therapeutic effect in the postpartum period is to stimulate uterine smooth muscle contraction, leading to a firm fundus. A firm fundus indicates that the uterus is contracting effectively, which helps to compress blood vessels at the placental site and control postpartum bleeding. This is the desired outcome of methylergonovine administration.

The complication that poses the greatest risk for the client is hemorrhage as evidenced by their amount of lochia.

Rationale for correct answers

Postpartum hemorrhage (PPH) is a major concern when excessive lochia and a boggy uterus are present. The nurse’s assessment reveals a boggy fundus, which firmed with massage but then softened again, indicating uterine atony, a leading cause of PPH. Additionally, the saturation of the perineal pad with lochia rubra and small clots suggests ongoing bleeding that requires close monitoring.

Rationale for incorrect Response 1 options

• Infection: No fever (≥38°C or 100.4°F) or foul-smelling lochia, which would indicate postpartum endometritis.
• Thrombophlebitis: No calf pain, swelling, or localized tenderness suggesting deep vein thrombosis.
• Mastitis: Breasts are soft, warm, and tender but without redness or localized pain, making mastitis unlikely.

Rationale for incorrect Response 2 options

• Breast tenderness: Expected due to milk production, not indicative of infection or complications.
• Calf pain: No evidence of thrombophlebitis or deep vein thrombosis.
• Fever: Temperature is normal at 37.2°C, ruling out systemic infection.