A nurse is assisting with the care of a client who is in labour and has an external electronic fetal monitor. The nurse observes that the fetal heart rate begins to decelerate after the contraction has started, with the lowest point of the deceleration occurring after the peak of the contraction. Which of the following actions should the nurse take first?

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.

The correct answer is choice B: Apply an ice pack to the perineum. This is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery, as it helps reduce swelling and provide pain relief.

Choice A rationale:

Placing a soft pillow under the client’s buttocks may provide comfort, but it does not directly address the inflammation and pain associated with an episiotomy. It is not the primary intervention for unrelieved episiotomy pain shortly after delivery.

Choice B rationale:

Applying an ice pack to the perineum is a standard practice for reducing pain and swelling after an episiotomy. The cold temperature causes vasoconstriction, which can help to decrease swelling and provide pain relief. This is especially effective within the first 24 hours post-delivery.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not recommended immediately following the procedure, as heat can increase blood flow to the area, potentially worsening swelling and pain in the acute phase after the surgery.

Choice D rationale:

While a warm sitz bath may be beneficial for episiotomy pain relief, it is typically recommended after the initial 24-hour period post-delivery. In the first 24 hours, cold therapy is preferred to reduce acute inflammation and pain.