A nurse is assessing a client who is postpartum and is experiencing hemorrhagic shock.
Which of the following findings should the nurse expect?

Choice A rationale: Uterine contractions occurring every 2 to 3 minutes at 30 weeks gestation are abnormal and indicate preterm labor. Normal uterine activity in the third trimester should not demonstrate such frequency or cervical change until term. The presence of cervical dilation (2 cm) and effacement (80%) confirms labor physiology. Preterm labor poses risks of neonatal respiratory distress, intraventricular hemorrhage, and sepsis. Therefore, this finding requires immediate follow-up to prevent complications associated with premature birth.

Choice B rationale: Abdominal assessment revealed a soft, nontender abdomen with no rebound tenderness. These findings are within normal limits and do not suggest acute abdominal pathology such as placental abruption, appendicitis, or peritonitis. In obstetrics, concerning abdominal findings would include rigidity, tenderness, or guarding. The absence of these signs indicates no emergent intra-abdominal complication. Thus, this assessment does not require follow-up, as it reflects a physiologically normal abdominal exam for a pregnant client.

Choice C rationale: Fundal height at 30 weeks gestation is expected to measure approximately 28 to 32 cm, correlating with gestational age ±2 cm. This client’s fundal height of 28 cm falls within the normal range. Deviations greater than 3 cm could indicate intrauterine growth restriction, oligohydramnios, or macrosomia. Since the measurement is consistent with gestational norms, it does not require follow-up. This finding is physiologically appropriate and does not suggest pathology or abnormal fetal growth at this stage of pregnancy.

Choice D rationale: Abdominal cramping in the third trimester, when associated with cervical dilation and effacement, is a hallmark of preterm labor. Unlike benign Braxton Hicks contractions, which are irregular and non-progressive, these cramps are accompanied by cervical change and regular contractions. This indicates true labor physiology before 37 weeks. Preterm labor increases risks of neonatal morbidity and mortality. Therefore, abdominal cramping in this context requires follow-up to initiate interventions such as tocolysis, corticosteroids, and infection evaluation.

Choice E rationale: Low back pain in pregnancy can be benign due to musculoskeletal strain, but in this case, it is associated with uterine contractions, cervical change, and rupture of membranes. Low back pain is a common presenting symptom of preterm labor due to referred pain from uterine activity. Additionally, fever (38.3°C) and elevated WBC count (22,000/mm³; normal 5,000–10,000/mm³) raise concern for intra-amniotic infection. Thus, low back pain here is pathologic and requires follow-up to rule out chorioamnionitis and manage preterm labor.

Choice A rationale

Hydrotherapy, like immersion in a tub or shower, is a nonpharmacological comfort measure for labor pain management. The therapeutic temperature of the water should indeed be maintained between 36 to 37°C (about 96.8 to 98.6°F). This range ensures the water is comfortably warm, promoting muscle relaxation, reducing pain perception, and avoiding potential maternal hyperthermia or fetal distress due to extreme temperatures.

Choice B rationale

Counterpressure is a technique used to relieve back pain caused by pressure of the fetal occiput against the sacrum, commonly known as "back labor.”. It involves steady, strong pressure applied by a support person to the sacral area or lower back, not the upper abdomen. Applying pressure to the upper abdomen would be ineffective and potentially uncomfortable for the client.

Choice C rationale

Effleurage is a light, rhythmic, stroking massage, often applied to the abdomen, used primarily during contractions in the first stage of labor to promote relaxation and distract from pain. It is generally not used during the pushing phase (second stage), as the client's focus shifts to bearing down and expelling the fetus, making effleurage distracting and ineffective.

Choice D rationale

Transcutaneous Electrical Nerve Stimulation (TENS) involves applying mild electrical currents via electrodes to the skin. During labor, the electrodes are typically placed on the lower back (sacral area) to block pain signals related to contractions as they travel up the spinal cord. Applying the TENS unit to the lower abdomen is not the standard placement for optimal labor pain relief.