A nurse is planning to obtain a blood specimen from a newborn via a heel stick.
Which of the following actions should the nurse take?

Choice A rationale

Repeating the CST isn't necessary with a negative result, which indicates no significant uterine contractions affecting the fetus.

Choice B rationale

Administering an IV fluid bolus is not warranted by a negative CST result.

Choice C rationale

Preparing for a cesarean birth isn't necessary since a negative CST indicates no immediate fetal distress.

Choice D rationale

A negative CST indicates that there are no late decelerations, so the nurse should allow the labor to progress naturally.

Choice A rationale

An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.

Choice B rationale

While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.

Choice C rationale

Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.

Choice D rationale

Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.