A nurse is caring for a group of clients on a postpartum unit.
Which of the following findings should be reported to the RN immediately?

Choice A rationale:

Significance of retraction: Retraction of the fetal head against the maternal perineum is a crucial sign that the fetal shoulders

are about to be delivered. It indicates that the fetal head has fully descended into the pelvic outlet and is ready to rotate and

deliver the shoulders.

Urgency of preparation: It's essential for the nurse to promptly prepare for the delivery of the shoulders to ensure a safe and

timely birth:

Gather necessary equipment, including sterile gloves, towels, and possibly a suction bulb.

Position the mother appropriately, often in a semi-sitting or lithotomy position, to facilitate delivery.

Support the perineum to reduce tearing and guide the delivery of the shoulders.

Communicate with the mother to encourage effective pushing and maintain clear instructions throughout the process.

Anticipate potential complications, such as shoulder dystocia, and be prepared to assist with maneuvers to resolve it if

necessary.

Choice B rationale:

Rest during second stage: While rest is important during labor, encouraging rest between contractions at this specific point

(retraction of the head) could delay the delivery of the shoulders, potentially increasing risks for both mother and baby.

Maintaining momentum: The second stage of labor typically involves active pushing and uterine contractions to facilitate

delivery. Resting at this stage could interrupt the natural progression of labor.

Choice C rationale:

Role of blood pressure monitoring: Monitoring blood pressure is essential throughout labor to detect potential complications

like preeclampsia or hemorrhage. However, in this specific scenario, where the fetal head is already retracted and the

shoulders are imminent, preparing for delivery takes priority over routine blood pressure checks.

Choice D rationale:

Oxygen administration: Oxygen is sometimes administered during labor to support the mother's and baby's oxygen levels.

However, it's not a standard intervention for all laboring women, and its necessity would be based on individual assessments

and clinical judgment. In the absence of specific indications for oxygen, such as maternal distress or fetal heart rate concerns,

it's not the priority action when the fetal head is retracted and delivery of the shoulders is impending.

Choice A rationale:

A full bladder can displace the uterus to the right and interfere with its ability to contract properly. This can lead to

postpartum hemorrhage, a serious complication that can occur after childbirth.

Emptying the bladder helps to reposition the uterus in the midline and allows it to contract more effectively. This helps to

prevent postpartum hemorrhage and promotes uterine involution, the process by which the uterus returns to its pre-

pregnancy size.

In this case, the client's fundus is firm, which indicates that it is contracting well. However, it is slightly deviated to the right,

which suggests that the bladder may be full.

Asking the client to empty her bladder is a simple and effective way to address this potential problem.

Choice B rationale:

Repeating the client's temperature evaluation is not a priority action in this case. The client's vital signs are within normal

limits, and there is no indication of infection.

A temperature elevation could be a sign of infection, but it is not the most likely cause of the uterine deviation in this case.

Choice C rationale:

Encouraging the client to nurse more frequently may be helpful in stimulating milk production and uterine contractions.

However, it is not the most immediate priority in this case.

The client's breasts are soft, which suggests that she is not yet producing a significant amount of milk.

The priority is to address the potential problem of a full bladder, which could interfere with uterine involution.

Choice D rationale:

Checking for signs of a urinary tract infection is not a priority action in this case. The client does not have any urinary

symptoms, such as dysuria or frequency.

A urinary tract infection could cause a uterine deviation, but it is not the most likely cause in this case.