A nurse is collecting data from a client who is 24 hours postpartum.
Which of the following findings should the nurse expect?

Choice C rationale:

Monitoring contraction frequency is essential to assess the progression of labor. Contractions are the tightening and relaxing of the uterine muscles that help to dilate the cervix and push the baby down the birth canal. The frequency of contractions is measured in minutes from the beginning of one contraction to the beginning of the next. As labor progresses, contractions become more frequent, regular, and intense. Monitoring contraction frequency helps the nurse to determine the stage of labor, assess the effectiveness of interventions, and identify any potential complications.

Monitoring fetal heart rate is crucial to assess the well-being of the baby during labor. The fetal heart rate is normally between 110 and 160 beats per minute. A normal fetal heart rate indicates that the baby is getting enough oxygen and is not in distress. Variations in the fetal heart rate, such as decelerations or tachycardia, can indicate potential problems and may require intervention.

Choice A rationale:

Preterm labor is defined as labor that begins before 37 weeks of gestation. The client in this scenario is at 38 weeks of gestation, which is considered term. Therefore, preterm labor is not the most likely condition.

Choice B rationale:

The administration of medication and bed rest may be appropriate interventions for preterm labor, but they are not the most appropriate interventions for a client in labor at 38 weeks of gestation. At this stage of pregnancy, labor is considered to be full-term, and interventions are focused on supporting the normal labor process and ensuring the safety of the mother and baby.

Choice A rationale:

Preparing the client for an emergency cesarean birth is an important step, but it is not the first action the nurse should take.

The immediate priority is to relieve pressure on the cord to prevent or alleviate cord compression.

Choice B rationale:

Covering the cord with a sterile, moist saline dressing is done to prevent drying of the cord and to maintain blood flow.

However, this is not the first action to take. The priority is to relieve cord compression by changing the client’s position.

Choice C rationale:

While it is important to explain to the client what is happening, this should not be the first action. The nurse’s priority is to

ensure the safety of the mother and baby, which involves immediate interventions to relieve cord compression.

Choice D rationale:

Placing the client in a knee-chest or Trendelenburg position is the first action the nurse should take. This position helps to

reduce pressure on the cord, which can improve blood flow to the fetus. It is a critical intervention that can prevent serious

complications such as fetal hypoxia.