A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

This is the action that the nurse should take after recognizing an early deceleration of the fetal heart rate tracing. Early decelerations are symmetrical decreases and return-to-normal linked to uterine contractions¹. The decrease in heart rate occurs gradually, and the nadir of the deceleration occurs at the same time as the peak of the uterine contraction³. Early decelerations are caused by compression of the fetus's head during a uterine contraction, which can stimulate the vagus nerve and cause a decrease in the fetal heart rate⁴. Early decelerations are nothing to be alarmed about¹. They are considered normal and benign, as they do not affect fetal oxygenation or well-being³. Therefore, the nurse should continue to monitor the client and the fetal heart rate tracing and document the findings.

The other options are not correct because they are not appropriate actions for early decelerations.
a) Assist the client to lay on her right side.
This is not an appropriate action for early decelerations, as they are not caused by maternal position or uteroplacental insufficiency. Changing the maternal position may help improve fetal oxygenation and blood flow in cases of late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.
c) Discontinue the oxytocin.
This is not an appropriate action for early decelerations, as they are not caused by oxytocin administration or uterine hyperstimulation. Oxytocin is a hormone that stimulates uterine contractions and can be used to induce or augment labor. However, excessive or prolonged use of oxytocin can cause uterine fatigue and reduce its ability to contract after delivery, leading to uterine atony and postpartum hemorrhage². Oxytocin can also cause late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.

d) Administer oxygen at 8 L/min per mask.
This is not an appropriate action for early decelerations, as they are not caused by fetal hypoxia or acidosis. Oxygen administration may help improve fetal oxygenation and blood flow in cases of late or variable decelerations, which are signs of fetal distress¹. However, early decelerations do not indicate fetal distress and do not require any intervention.

Bladder distention is a common postpartum complication that can occur due to decreased bladder sensation, perineal edema, trauma, or pain after vaginal birth. Bladder distention can interfere with uterine contraction and involution, leading to increased bleeding and risk of infection. Therefore, it is important to assess and manage bladder distention promptly and effectively in postpartum clients.
The first action the nurse should take for a client who has bladder distention is to assist the client to the bathroom and encourage voiding. This is the least invasive and most natural way to empty the bladder and relieve the distention. The nurse should provide privacy, comfort, and support to the client, and help with perineal care after voiding. The nurse should also measure the urine output and monitor for signs of urinary retention or infection, such as dribbling, frequency, urgency, dysuria, hematuria, or foul-smelling urine.

b) Inserting a urinary catheter is not the first action the nurse should take for a client who has bladder distention. A urinary catheter is an invasive procedure that can introduce infection, trauma, or irritation to the urinary tract. It should be used only as a last resort when other methods of bladder emptying have failed or are contraindicated. The nurse should obtain a provider's order before inserting a urinary catheter and follow strict aseptic technique.
c) Offering the client a sitz bath is not the first action the nurse should take for a client who has bladder distention. A sitz bath is a warm water bath that covers only the hips and buttocks. It can provide comfort and promote healing for clients who have perineal lacerations, episiotomies, or hemorrhoids after vaginal birth. However, it does not directly address bladder distention or facilitate voiding. It may also increase the risk of infection or bleeding if done too soon or too frequently after delivery.
d) Pouring warm water over the client's perineum is not the first action the nurse should take for a client who has bladder distention. Pouring warm water over the perineum can help with perineal care and hygiene after vaginal birth. It can also stimulate voiding by creating a relaxing effect on the pelvic floor muscles. However, it does not ensure complete bladder emptying or relieve bladder distention. It may also cause discomfort or irritation if the water temperature or pressure is too high.