A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

Choice A reason:

Assisting the client into a comfortable position (Choice A) might be appropriate in some labor scenarios, but in this case, the client's sudden urge to push indicates that the baby's birth is imminent. Therefore, the nurse should focus on evaluating the stage of labor and preparing for delivery rather than repositioning the client.

Choice B reason:

Observing for crowning is essential, but it should be done after addressing the client's immediate urge to push. Crowning indicates that the baby is very close to being born, but at 7 cm dilation, the client is not yet in the second stage of labor where pushing is appropriate.

Choice C reason:

Panting helps the client manage the urge to push and prevents premature pushing, which can cause cervical swelling or injury. This technique helps delay pushing until full dilation is achieved, ensuring a safer delivery process.
Choice D reason:

Helping the client to the bathroom to void (Choice D) is not advisable at this point. The client's urge to push indicates that the baby is descending, and birth is imminent. It would not be safe to have the client walk to the bathroom at this stage, as she may deliver the baby during the process, increasing the risk of an unattended birth.

Choice A reason:

Uteroplacental insufficiency is a condition where the placenta cannot deliver enough oxygen and nutrients to the fetus. This can cause fetal hypoxia and distress, which can be detected by late decelerations on the fetal heart rate monitor. Late decelerations are defined as a decrease in the fetal heart rate that begins after the peak of the contraction and returns to baseline after the contraction ends. This indicates that the fetus is not tolerating the reduced blood flow during the contractions and needs immediate intervention. • Choice B reason:

Umbilical cord compression is a condition where the umbilical cord is squeezed or twisted, reducing the blood flow and oxygen to the fetus. This can cause variable decelerations on the fetal heart rate monitor. Variable decelerations are defined as a decrease in the fetal heart rate that varies in timing, shape, and duration, and may or may not be associated with contractions. This indicates that the fetus is experiencing intermittent or sustained cord compression and may need repositioning or other interventions. • Choice C reason:

Maternal bradycardia is a condition where the mother's heart rate is slower than normal, usually less than 60 beats per minute. This can cause reduced blood flow and oxygen to the placenta and the fetus, but it does not cause late decelerations on the fetal heart rate monitor. Maternal bradycardia can be caused by various factors, such as medications, hypothermia, hypothyroidism, or vagal stimulation. It may need treatment depending on the cause and severity. • Choice D reason:

Fetal head compression is a condition where the fetal head is pressed against the cervix or the pelvic floor during labor, stimulating the vagus nerve and slowing down the fetal heart rate. This can cause early decelerations on the fetal heart rate monitor. Early decelerations are defined as a decrease in the fetal heart rate that begins with the onset of the contraction and returns to baseline with the end of the contraction. This indicates that the fetus is descending in the birth canal and is usually a normal and benign finding.