Which of the following assessments is the nurse’s highest priority for a client in labor who has an epidural in place and is on continuous internal monitoring with a fetal scalp electrode and intrauterine pressure catheter, noting a strong contraction on the monitor and the client reporting nausea accompanied by an urgent need to have a bowel movement?

Choice A reason: Early decelerations of the FHR result from head compression during contractions, a benign response reflecting vagal stimulation. They mirror contraction patterns and do not indicate fetal distress. Epidural analgesia may reduce maternal blood pressure, but early decelerations are unrelated to hypoxia, requiring no immediate reporting in this context.

Choice B reason: FHR accelerations of 15 beats/min for 15 seconds indicate fetal well-being, reflecting a responsive autonomic nervous system. They occur with fetal movement or stimulation and are not concerning. Epidural analgesia does not typically cause accelerations, and these findings do not warrant reporting, as they signify normal fetal oxygenation and neurological function.

Choice C reason: An FHR of 150/min is within the normal range (110-160/min) and does not indicate distress. Epidural analgesia may cause maternal hypotension, affecting placental perfusion, but a stable FHR within normal limits reflects adequate fetal oxygenation. This finding does not require immediate reporting, as it aligns with normal fetal physiology.

Choice D reason: Prolonged absent FHR variability suggests fetal compromise, as variability reflects autonomic nervous system function and oxygenation. Epidural analgesia can cause maternal hypotension, reducing placental perfusion and leading to hypoxia, which diminishes variability. This critical finding requires immediate reporting to address potential fetal distress and prevent adverse outcomes like acidosis.

Choice A reason: Sternal retractions indicate respiratory distress, as the newborn uses accessory muscles to breathe, suggesting airway obstruction or lung immaturity. This requires immediate intervention to ensure oxygenation, as it may reflect transient tachypnea or pneumothorax, compromising alveolar gas exchange, per neonatal respiratory physiology.

Choice B reason: Molding, the temporary reshaping of the skull during vaginal birth, is normal due to cranial bone flexibility. It resolves spontaneously within days and does not affect neurological or respiratory function, requiring no intervention, as it aligns with the biomechanics of vaginal delivery and neonatal adaptation.

Choice C reason: Acrocyanosis, bluish discoloration of hands and feet, is normal in newborns due to immature peripheral circulation. It resolves as vascular tone stabilizes and does not indicate hypoxia, requiring no intervention. This physiological adaptation reflects normal thermoregulatory and circulatory adjustments in the immediate postnatal period.

Choice D reason: Vernix caseosa, a waxy skin coating, is a normal protective layer in newborns, aiding thermoregulation and skin hydration. It requires no intervention, as it naturally absorbs or is gently cleaned. Vernix supports skin barrier function and antimicrobial defense, aligning with neonatal dermatological physiology.