A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

Bladder distention is a common postpartum complication that can occur due to decreased bladder sensation, perineal edema, trauma, or pain after vaginal birth. Bladder distention can interfere with uterine contraction and involution, leading to increased bleeding and risk of infection. Therefore, it is important to assess and manage bladder distention promptly and effectively in postpartum clients.
The first action the nurse should take for a client who has bladder distention is to assist the client to the bathroom and encourage voiding. This is the least invasive and most natural way to empty the bladder and relieve the distention. The nurse should provide privacy, comfort, and support to the client, and help with perineal care after voiding. The nurse should also measure the urine output and monitor for signs of urinary retention or infection, such as dribbling, frequency, urgency, dysuria, hematuria, or foul-smelling urine.

b) Inserting a urinary catheter is not the first action the nurse should take for a client who has bladder distention. A urinary catheter is an invasive procedure that can introduce infection, trauma, or irritation to the urinary tract. It should be used only as a last resort when other methods of bladder emptying have failed or are contraindicated. The nurse should obtain a provider's order before inserting a urinary catheter and follow strict aseptic technique.
c) Offering the client a sitz bath is not the first action the nurse should take for a client who has bladder distention. A sitz bath is a warm water bath that covers only the hips and buttocks. It can provide comfort and promote healing for clients who have perineal lacerations, episiotomies, or hemorrhoids after vaginal birth. However, it does not directly address bladder distention or facilitate voiding. It may also increase the risk of infection or bleeding if done too soon or too frequently after delivery.
d) Pouring warm water over the client's perineum is not the first action the nurse should take for a client who has bladder distention. Pouring warm water over the perineum can help with perineal care and hygiene after vaginal birth. It can also stimulate voiding by creating a relaxing effect on the pelvic floor muscles. However, it does not ensure complete bladder emptying or relieve bladder distention. It may also cause discomfort or irritation if the water temperature or pressure is too high.

Late decelerations are a type of fetal heart rate (FHR) pattern that indicate fetal hypoxia (lack of oxygen) due to uteroplacental insufficiency (decreased blood flow to the placenta). They are defined as a gradual decrease in FHR that occurs after the peak of a uterine contraction and returns to baseline after the end of the contraction¹. Late decelerations are associated with adverse neonatal outcomes, such as low Apgar scores, acidosis, and neonatal intensive care unit admission².
The nurse should take immediate actions to improve fetal oxygenation and blood flow when late decelerations are detected. The first and most important action is to place the client in a lateral position, either left or right, to reduce compression of the inferior vena cava and increase uterine perfusion. This can improve fetal oxygenation and reduce the severity of late decelerations¹³.
The other actions that the nurse should take are:
- Discontinue oxytocin infusion if it is being used for induction or augmentation of labor, as it can cause uterine tachysystole (excessive contractions) and worsen uteroplacental insufficiency¹³.
- Administer oxygen to the client at 8 to 10 L/min via a nonrebreather face mask to increase maternal oxygen saturation and fetal oxygen delivery¹³.
- Increase intravenous (IV) fluid infusion rate to maintain maternal hydration and blood pressure, which can improve uterine blood flow¹³.
- Notify the provider and prepare for possible operative delivery if late decelerations persist or fetal distress occurs¹³.
- Provide emotional support and reassurance to the client and family, as late decelerations can cause anxiety and fear⁴.

The other options are not actions that the nurse should take:
- a) Administer misoprostol 25 mcg vaginally. This is not correct because misoprostol is a medication that is used to induce labor by ripening the cervix and stimulating contractions. It is not indicated for late decelerations and can cause uterine hyperstimulation and fetal distress⁵.
- c) Administer oxygen via a face mask at 2 L/min. This is not correct because this is too low of an oxygen flow rate to improve fetal oxygenation. The recommended oxygen flow rate for late decelerations is 8 to 10 L/min via a nonrebreather face mask¹³.
- d) Decrease the maintenance IV solution infusion rate. This is not correct because this can cause maternal dehydration and hypotension, which can reduce uterine blood flow and worsen fetal hypoxia. The nurse should increase the IV fluid infusion rate to maintain maternal hydration and blood pressure¹³.