When contributing to the plan of care for the 4th stage of labor, the nurse should recognize the client is at the greatest risk of developing which of the following complications?

Choice A rationale:
Severe nausea and vomiting are not indicative of an ectopic pregnancy. While nausea and vomiting are common symptoms in early pregnancy, they are not specific to ectopic pregnancies. These symptoms are more likely associated with typical pregnancy changes.

Choice B rationale:
Pelvic pain is a crucial finding that the nurse should expect in a possible ectopic pregnancy. As the pregnancy implants outside of the uterus, usually in the fallopian tube, it can cause sharp and severe pain in the pelvic region. This pain may be unilateral and can be accompanied by shoulder pain due to blood or fluid irritating the diaphragm.

Choice C rationale:
Uterine enlargement greater than expected for gestational age is not likely in an ectopic pregnancy. In fact, uterine enlargement may not be noticeable at all in an ectopic pregnancy since the embryo is not developing in the uterus.

Choice D rationale:
Copious vaginal bleeding is more commonly associated with miscarriages or other complications in intrauterine pregnancies. In an ectopic pregnancy, vaginal bleeding may occur, but it is typically lighter and often described as spotting.

Choice A rationale:

The nurse should not advise the client to take deep, cleansing breaths before and after each contraction because it can interfere with the natural urge to push and may not be effective in helping with the labor process. When a client feels the urge to push, it is essential to work with their body's natural instincts.

Choice B rationale:

Instructing the client to hold their breath and push while counting to ten is not recommended. This Valsalva manoeuvre can cause a sudden increase in intra-abdominal pressure, which may reduce blood flow to the heart and brain and may be harmful to both the client and the baby. It's crucial to promote safe pushing techniques during labor.

Choice C rationale:

The instruction to push continuously throughout the entire contraction is also not ideal. Pushing continuously can lead to exhaustion and decrease the effectiveness of each push. It's essential to guide the client on when and how to push effectively to prevent unnecessary fatigue.

Choice D rationale:

The correct instruction is to let the client know when to push according to their contractions. The urge to push is a natural reflex that signifies the baby's descent into the birth canal. The nurse should encourage the client to listen to their body and push when they feel the urge during the contractions. This approach optimizes the client's efforts and conserves their energy for delivery.