A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform?

Choice A Reason:

Reassess the client in 2 hours is inappropriate. While reassessment is important, addressing the cause of uterine displacement, in this case, a full bladder, should be the initial priority.

Choice B Reason:

Administering simethicone is inappropriate. Simethicone is typically used to relieve gas and bloating. It is not the primary intervention for uterine displacement related to bladder fullness.

Choice C Reason:

Assisting the client to empty her bladder is appropriate. A full bladder can displace the uterus and hinder its contraction, leading to potential issues such as uterine atony or increased postpartum bleeding. Emptying the bladder helps the uterus contract more effectively.

Choice D Reason:

Instructing the client to lie on her right side is inappropriate. Lying on the right side is often recommended to improve blood flow and oxygenation to the fetus during pregnancy but may not directly address uterine displacement caused by a full bladder. The priority is to assist the client in emptying her bladder.

The correct answer is A.

A. Shortness of breath: Shortness of breath can be a serious side effect of combined oral contraceptives (COCs) and may indicate a potential risk of a blood clot or other cardiovascular issues. It is crucial for the client to seek medical attention promptly if experiencing shortness of breath.

B. Breakthrough bleeding: Breakthrough bleeding is a common side effect of COCs, especially during the first few months of use. While it can be bothersome, it is generally not considered a serious adverse effect. However, the healthcare provider may need to adjust the dosage or type of contraceptive if breakthrough bleeding persists.

C. Vomiting: Vomiting can decrease the absorption of COCs, and if vomiting occurs within a few hours after taking the pill, a backup form of contraception may be needed. However, it is not necessarily an adverse effect that requires immediate notification unless it leads to an inability to take the medication consistently.

D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives and is generally not considered a serious adverse effect. Clients are often advised to monitor for changes in breast tenderness, but it does not require immediate notification.