As a woman enters the second stage of labor, her membranes spontaneously rupture. What action should the nurse take?

A) Ask the client to empty their bladder:
One of the first actions the nurse should take when the uterus is not firm (often referred to as uterine atony) is to ask the client to empty their bladder. A full bladder can interfere with uterine contraction and cause the uterus to be boggy or soft, which can lead to postpartum hemorrhage. Encouraging the client to void may help the uterus contract more effectively and reduce the risk of complications.

B) Perform fundal massage:
If the uterus is not firm, performing a fundal massage is essential. Fundal massage helps stimulate uterine contractions and helps the uterus contract to its normal size, reducing the risk of bleeding. It is a critical intervention in postpartum care to ensure that the uterus remains firm and does not become atonic, which can cause excessive blood loss.

C) Nothing, this is an expected finding:
A soft uterus (uterine atony) is not an expected finding 4 hours postpartum. A firm uterus is expected at this point to prevent hemorrhage. The nurse should take immediate action to address the issue of uterine atony, as failure to do so can lead to significant postpartum hemorrhage, a life-threatening complication.

D) Ambulate the client in the hallway:
Ambulation may be helpful later in the postpartum period to encourage circulation and prevent thromboembolism, but it is not a priority when the uterus is not firm. The first priority is to address uterine atony, and actions like emptying the bladder and massaging the fundus should be performed before ambulating the client.

E) Give pain medications:
While pain management is important, it is not the priority intervention when the uterus is not firm. The nurse must first address the cause of uterine atony (such as bladder distention) and stimulate uterine contractions via fundal massage to ensure that the uterus is firm and the client is not at risk for excessive bleeding. Pain medications can be given once the immediate uterine concerns have been addressed.

A) Fusion of labia in female genitalia:
Fusion of the labia in a female newborn is not an expected finding. This could indicate a condition such as labial adhesion or an abnormality in the development of the genitalia. Normally, the labia in a female newborn are separated. Any signs of fusion would require further evaluation by the healthcare provider.

B) Erythema toxicum on newborn's skin:
Erythema toxicum is a common and expected finding in newborns, usually appearing within the first 2–3 days of life. It consists of small, red papules or pustules on a red base, often described as a "flea-bitten" appearance. This rash is benign and resolves on its own within a few days to weeks. It is not associated with any infection or underlying health issues.

C) Hypospadias is noted in the male newborn:
Hypospadias, a condition where the urethral opening is located on the underside of the penis rather than at the tip, is not an expected finding in all newborn males. While it occurs in a small percentage of male infants, it is a congenital anomaly that would require further assessment and possibly surgical correction. It is not considered a normal finding in a newborn.

D) Presence of syndactyly in extremities:
Syndactyly, the condition where two or more fingers or toes are fused together, is not a normal finding in newborns. While it is a congenital anomaly that can occur in some infants, it is not expected and requires further evaluation and possibly surgical intervention depending on the severity.

E) Negative Ortolani sign:
A negative Ortolani sign is an expected and normal finding in a newborn. The Ortolani maneuver is used to assess for hip dislocation, and a negative result indicates that the hip is stable and not dislocated. If the Ortolani sign were positive, it would suggest the presence of a developmental hip dysplasia, which would require further diagnostic evaluation. A negative sign is considered typical and reassuring.