In which clinical situation would the nurse most likely anticipate a fetal bradycardia?

The complication that poses the greatest risk for the client is hemorrhage as evidenced by their amount of lochia.

Rationale for correct answers

Postpartum hemorrhage (PPH) is a major concern when excessive lochia and a boggy uterus are present. The nurse’s assessment reveals a boggy fundus, which firmed with massage but then softened again, indicating uterine atony, a leading cause of PPH. Additionally, the saturation of the perineal pad with lochia rubra and small clots suggests ongoing bleeding that requires close monitoring.

Rationale for incorrect Response 1 options

• Infection: No fever (≥38°C or 100.4°F) or foul-smelling lochia, which would indicate postpartum endometritis.
• Thrombophlebitis: No calf pain, swelling, or localized tenderness suggesting deep vein thrombosis.
• Mastitis: Breasts are soft, warm, and tender but without redness or localized pain, making mastitis unlikely.

Rationale for incorrect Response 2 options

• Breast tenderness: Expected due to milk production, not indicative of infection or complications.
• Calf pain: No evidence of thrombophlebitis or deep vein thrombosis.
• Fever: Temperature is normal at 37.2°C, ruling out systemic infection.

Choice A rationale

While assessing cervical dilation is important for understanding the progress of labor, it is not the priority intervention in the case of umbilical cord prolapse. The immediate danger is fetal oxygen deprivation due to compression of the prolapsed cord. Delaying intervention to perform a cervical exam could worsen fetal hypoxia.

Choice B rationale

Increasing the rate of intravenous fluids might be indicated to support maternal blood pressure and placental perfusion, but it does not directly address the immediate problem of cord compression. The priority is to relieve pressure on the umbilical cord to restore fetal oxygen supply.

Choice C rationale

Administering oxygen to the mother is a helpful supportive measure to increase the oxygen available to the fetus. However, it does not directly relieve the compression on the umbilical cord, which is the immediate life-threatening situation for the fetus.

Choice D rationale

Repositioning the mother to a knee-chest position (or Trendelenburg) uses gravity to help relieve pressure on the prolapsed umbilical cord by moving the presenting part of the fetus away from the pelvis. This is the priority nursing intervention as it directly aims to improve fetal oxygenation by reducing cord compression until the fetus can be delivered. .