A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

Choice A rationale:

Petroleum jelly is a common recommendation to apply during diaper changes for circumcised newborns. It acts as a barrier between the diaper and the healing penis, reducing friction and preventing the diaper from sticking to the sensitive area. This can help promote better healing and prevent discomfort for the newborn.

Choice B rationale:

Pre-moistened towelettes are not typically recommended for application on the penis of a circumcised newborn during diaper changes. These towelettes may contain chemicals or irritants that could potentially irritate the delicate skin of the healing area.

Choice C rationale:

Povidone-iodine is an antiseptic solution often used to disinfect the skin before procedures or surgeries. However, it is not recommended for routine use on the penis of a circumcised newborn during diaper changes as it may be too harsh for the healing skin.

Choice D rationale:

Silver sulfadiazine is a topical antimicrobial agent used for treating burns and certain infections. However, it is not indicated for use on a circumcised newborn's penis during diaper changes. The healing process after circumcision does not usually involve infections that require this type of treatment.

Choice A rationale:

Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.

Choice B rationale:

Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.

Choice C rationale:

Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.

Choice D rationale:

Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.