A nurse is monitoring a client who is in the active phase of labor and has an electronic fetal monitor.
Which of the following findings should the nurse expect?

Choice A rationale: Stopping breastfeeding is not indicated in postpartum infections unless the infection is a contraindication such as HIV or active tuberculosis. Breastfeeding promotes uterine contraction by releasing oxytocin, which helps reduce bleeding and promotes healing. Additionally, breast milk provides immunological benefits to the newborn. The client’s infection appears localized to the uterus (endometritis), and there is no evidence breastfeeding worsens maternal infection or neonatal risk here.

Choice B rationale: Initiating broad-spectrum antibiotics is scientifically appropriate for suspected postpartum endometritis, especially with fever >38°C, tachycardia, foul-smelling lochia, and abdominal tenderness. These antibiotics target polymicrobial infections commonly involving aerobic and anaerobic bacteria, preventing progression to sepsis. Timely antibiotic therapy reduces maternal morbidity and accelerates recovery. Normal temperature is 36.5–37.5°C; this client’s rising fever to 38.9°C indicates infection requiring treatment.

Choice C rationale: Airborne isolation precautions are unnecessary because common postpartum infections such as endometritis are not transmitted via airborne routes but rather by endogenous flora or direct contamination. Airborne pathogens include tuberculosis, varicella, and measles, none of which are suggested by this client’s presentation or history. Implementing unnecessary airborne precautions wastes resources and increases patient isolation without scientific benefit.

Choice D rationale: Strict bedrest is not routinely indicated in postpartum infections unless severe systemic illness is present. Early mobilization improves circulation, reduces risk of venous thromboembolism, and promotes pulmonary function, especially when respiratory rate is elevated at 24/min. The client is alert and breastfeeding, suggesting stable condition. Prolonged immobility increases risks without benefits in mild-to-moderate infection management.

Choice A rationale

Uterine contractions every 15 minutes are characteristic of the latent phase of labor, not the active phase. In the active phase, contractions typically become stronger, more frequent, and more regular, occurring every 2 to 5 minutes, signifying progressive cervical dilation.

Choice B rationale

A fetal heart rate (FHR) baseline of 166/min with minimal variability is concerning. While a baseline up to 160/min is generally normal, 166/min is slightly elevated, and minimal variability (5 bpm or less) can indicate fetal hypoxia or acidosis, necessitating further assessment and intervention. Normal FHR baseline is 110-160 bpm.

Choice C rationale

Late decelerations in FHR are non-reassuring findings indicative of uteroplacental insufficiency, meaning inadequate oxygen transfer to the fetus. These decelerations suggest potential fetal distress and require immediate intervention and reporting to the provider, not an expected finding in active labor.

Choice D rationale

Contraction duration of 75 seconds is an expected finding in the active phase of labor. During this phase, contractions typically last 45 to 90 seconds. This duration contributes to effective cervical effacement and dilation, signifying adequate uterine activity for labor progression.