A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

Choice A Reason:

Left upper quadrant is incorrect. The left upper quadrant is less likely to be the area where the point of maximum intensity of the fetal heart is heard when the fetal position is left occipital anterior.

Choice B Reason:

Right upper quadrant is incorrect. The right upper quadrant is not the typical location for assessing fetal heart tones when the fetal position is left occipital anterior. The heart tones are generally heard more towards the left side.

Choice C Reason:

Left lower quadrant is correct. Placing the ultrasound transducer in the left lower quadrant is likely to provide the best detection of the fetal heart tones in the described fetal position.

Choice D Reason:

Right lower quadrant is incorrect. Similar to the right upper quadrant, the right lower quadrant is not the optimal location for assessing the fetal heart when the fetal position is left occipital anterior. The left side is typically where the point of maximum intensity is found.

The correct answer is C. Continuous contraction lasting 2 min.

A. Pressure on the perineum causing the client to bear down is a common sign in the later stages of labor when the cervix is fully dilated. It is not typically a cause for immediate concern during the admission phase.

B. Expulsion of clear fluid from the vagina may be amniotic fluid, which can indicate rupture of membranes. While important to note, it is not as urgent as a prolonged contraction.

C. Continuous contraction lasting 2 min is a concerning finding and should be reported first.

A contraction lasting 2 minutes is excessively long and may lead to decreased uterine blood flow, affecting fetal oxygenation. It requires prompt attention from the healthcare provider.

D. Expulsion of a blood-tinged mucous plug, also known as the "bloody show," is a common occurrence in early labor and is not as urgent as the prolonged contraction.