A nurse is caring for a client who is having a vacuum-assisted birth.
Which of the following actions should the nurse take?

Choice A rationale

The vacuum cup for an assisted birth is strategically placed on the fetal occiput, which is the posterior aspect of the fetal skull, not in front of the fetal ears. Proper placement over the posterior fontanelle promotes traction directly on the bone, minimizing the risk of fetal scalp injury and ensuring efficient rotation and descent of the fetal head during traction. Positioning near the ears is incorrect and dangerous.

Choice B rationale

During a vacuum-assisted birth, the client is actively encouraged to push effectively with each uterine contraction, as the vacuum traction is applied only during a contraction. Maternal pushing augments the force of the vacuum device and facilitates the fetal head's descent through the birth canal, maximizing the procedure's success while minimizing the duration and number of pulls required for delivery.

Choice C rationale

Continuous fetal monitoring is absolutely essential throughout a vacuum-assisted birth procedure. It allows the nurse and provider to immediately assess the fetal heart rate (FHR) response to the procedure, identify potential complications like bradycardia or non-reassuring FHR patterns, and guide the discontinuation of the vacuum if fetal compromise is detected.

Choice D rationale

Administering a fluid bolus to ensure a full bladder is contraindicated during labor and birth. An empty bladder is preferred for fetal descent and to prevent obstruction of the birth canal. Furthermore, a full bladder can potentially be damaged by the descending fetal head, making bladder emptying (catheterization) common prior to assisted delivery if necessary.

Choice A rationale

A pain rating of 3/10 indicates mild pain and is a expected finding following a vaginal birth with a third-degree laceration repair. Pain alone is not the primary indicator for catheterization unless it is severe enough to prevent voiding. The focus for catheterization is on signs of urinary retention and its consequences, like uterine atony.

Choice B rationale

Lochia rubra (bright red discharge, typically lasting 1-3 days) is the expected type of lochia 4 hours postpartum, and a moderate amount is normal. The characteristics of lochia are indicators of uterine involution and healing, but do not directly confirm the need for a catheterization due to inability to void.

Choice C rationale

Ecchymosis (bruising) and edema of the perineum are expected signs following a vaginal birth, especially with a laceration and repair. While swelling can sometimes contribute to difficulty voiding, it is an expected localized finding and not the most direct indicator that immediate straight catheterization is required to manage urinary retention.

Choice D rationale

A boggy (soft, not contracted) and deviated uterus is the most critical sign indicating a full or distended bladder preventing the uterus from contracting effectively. This distention leads to urinary retention and significantly increases the client's risk for postpartum hemorrhage. Immediate straight catheterization is necessary to empty the bladder and allow the uterus to firm up.