A nurse is assisting with the care of a client who is in active labor.The fetal monitor tracing shows late decelerations.
Which of the following actions should the nurse take first?

Choice A rationale

Leukorrhea, a normal vaginal discharge, increases during pregnancy due to hormonal changes. It's not indicative of prenatal complications at 41 weeks of gestation.

Choice B rationale

Shortness of breath is common in late pregnancy due to the enlarged uterus pressing against the diaphragm. It is not necessarily a sign of a prenatal complication at this stage.

Choice C rationale

Non-pitting ankle edema is often seen in late pregnancy due to fluid retention and increased pressure on the veins. It is typically benign and not a sign of serious complications.

Choice D rationale

Blurred vision can indicate a serious prenatal complication such as preeclampsia, which is characterized by high blood pressure and can pose significant risks to both mother and baby if not managed properly. .

Choice A rationale:

Deep tendon reflexes of 1+ are considered normal for a postpartum client and do not typically require immediate follow-up. They indicate slight but definite muscle contraction with reinforcement.

Choice B rationale:

Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. Immediate follow-up is necessary to address this issue.

Choice C rationale:

A blood pressure of 136/86 mm Hg is within the normal range for a postpartum client and does not require immediate follow-up unless there are other symptoms of preeclampsia or hypertension.

Choice D rationale:

A pain rating of 3 on a scale of 0 to 10 is mild and is expected in the postpartum period. It does not require immediate follow-up unless the pain is severe or unrelieved.

Choice E rationale:

Soft breasts in the immediate postpartum period are normal as milk production has not yet fully begun. This does not require immediate follow-up.

Choice F rationale:

A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. This requires immediate follow-up and intervention to ensure the uterus is contracting properly.

Choice G rationale:

A large amount of lochia rubra can be a sign of postpartum hemorrhage. Immediate follow-up is necessary to assess and manage bleeding.

Choice H rationale:

Peripheral edema of 2+ in the bilateral lower extremities is common in postpartum clients due to fluid shifts and does not typically require immediate follow-up unless accompanied by other concerning symptoms.