A nurse on a postpartum unit is caring for a client.

Exhibits

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Nurses' Notes

2hr postpartum:

Client is 2 hr postpartum following vaginal delivery. Client alert and oriented. Lungs clear to auscultation bilaterally. S1 S2 auscultated, no murmur. Abdomen soft, nontender. Uterus firm and midline, 1 cm below the umbilicus. Moderate amount of lochia rubra present on perineal pad.

24 hr postpartum:

Client alert and oriented. Lungs clear to auscultation bilaterally. S1,S2 auscultated, no murmur. Abdomen soft, nontender. Uterus boggy and midline, 2 cm below the umbilicus. Moderate amount of lochia rubra present on perineal pad, foul odor present.

Vital signs:

1 hr postpartum:

Temperature 37.5° C (99.5° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 118/78 mm Hg

24 hr postpartum:

Temperature 38.3° C (100.9° F)

Heart rate 105/min

Respiratory rate 18/min

Blood pressure 115/78 mm Hg

Uterine rupture: A client in active labor with a history of prior vaginal birth is at risk for uterine rupture, particularly when experiencing intense contractions and increasing pelvic pressure. While previous vaginal delivery lowers the risk compared to a history of cesarean section, prolonged or strong contractions can still contribute to uterine rupture, especially if there is an undiagnosed uterine scar or excessive uterine stress.

Increasing pelvic pressure: The client reports increasing pelvic pressure despite receiving an epidural, which can be a sign of impending uterine rupture. While pelvic pressure is expected during labor, a sudden or intense sensation, particularly in the setting of strong contractions and rapid cervical dilation, warrants close monitoring.

A) "There are specific pain management options that you need to use":
It’s important to respect the client's autonomy and work collaboratively to explore pain management options that align with their cultural values and medical safety. A more open, client-centered approach would be more beneficial.

B) "We will work with you to incorporate the practices that are safe for you and your fetus.":
This statement acknowledges the client's cultural preferences while ensuring that safety is the priority. The nurse is offering to collaborate with the client to explore pain management options that align with their values, within the scope of what is medically safe for both the mother and the fetus. It promotes a partnership approach, which is critical in maternity care.

C) "You will need to discuss this with the provider.":
While the provider may ultimately be involved in deciding specific pain management options, this statement dismisses the nurse's role in supporting the client’s cultural preferences. Nurses can play an active role in initiating and facilitating these conversations with clients and helping them express their preferences to the provider. It is not solely the provider's responsibility.

D) "It is better to use pain management options that have been researched.":
While evidence-based practices are important, this statement could be seen as dismissive of the client's cultural preferences. It fails to address the importance of individualized care and overlooks the possibility of integrating safe, culturally relevant pain management practices alongside researched methods. A balanced approach that respects both cultural values and medical safety is crucial.