A nurse is caring for a newborn 4 hours after their birth.
Which of the following findings should the nurse report to the provider?

Choice A rationale

Sequential compression devices (SCDs) are applied preoperatively to promote venous return and prevent venous stasis in the lower extremities, significantly reducing the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE), which are critical concerns during and after major surgery like a cesarean birth. Prophylaxis should commence before the operation for maximal effect.

Choice B rationale

An indwelling urinary catheter is typically inserted prior to the cesarean section, after the client receives regional anesthesia, to ensure the bladder is empty during the procedure, preventing injury to the bladder by the surgeon and maintaining a clear surgical field. It is not delayed until immediately following the procedure.

Choice C rationale

Oxytocin is a uterotonic agent administered post-delivery of the placenta (not prior to the procedure) via continuous IV infusion to stimulate uterine contractions, which is crucial for preventing postpartum hemorrhage by promoting myometrial contraction and vessel constriction.

Choice D rationale

The surgical timeout, a critical patient safety measure that verifies the correct patient, procedure, and surgical site, is performed by the entire surgical team immediately prior to the incision, typically after the client enters the operating room and is prepped, not while they are in the preoperative holding area.

Choice A rationale

Initiating internal fetal heart rate monitoring is an invasive procedure that is not the priority for a non-reassuring fetal heart rate pattern like late decelerations, which often indicate uteroplacental insufficiency. The first step involves non-invasive intrauterine resuscitation measures to immediately improve fetal oxygenation before considering invasive monitoring, unless the external tracing is inadequate.

Choice B rationale

Late decelerations are an indication of uteroplacental insufficiency (decreased blood flow/oxygen to the fetus during the contraction). Assisting the client to a left lateral position is the priority nursing action because it relieves pressure from the gravid uterus on the vena cava, which in turn maximizes venous return to the heart and increases blood flow and oxygen delivery to the placenta and fetus.

Choice C rationale

While uterine tachysystole (excessive frequency of contractions, greater than five in 10 minutes over 30 minutes) can cause late decelerations, palpating for it is not the absolute first action. The immediate priority is to improve fetal oxygenation by repositioning the mother. Palpation for tachysystole, however, is a quick assessment that should follow the repositioning intervention.

Choice D rationale

Increasing the infusion rate of the maintenance IV fluid (an IV fluid bolus) is a critical step in intrauterine resuscitation for late decelerations. It increases maternal blood volume, which can improve placental perfusion. However, repositioning the client is generally the most immediate, least invasive, and first step to correct or improve the blood flow to the placenta and fetus.