The nurse is reviewing the client’s chart.

Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage.

Client was middle aged and married.

She was in labor for 25 hours and forceps were used to assist with the delivery.

She was given an epidural for anesthesia that was effective.

The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale.

Her vital signs were stable, and she was catheterized for 500 mL of light-yellow urine just prior to delivery.

Her spouse was at the bedside for delivery.

Choice A rationale
Fetal head compression is not the cause of late decelerations. Fetal head compression occurs when the fetal head is pressed against the maternal pelvis or cervix during labor. This can cause early decelerations, which are symmetrical decreases in the fetal heart rate that coincide with the uterine contractions.

Choice B rationale
Umbilical cord compression is not the cause of late decelerations. Umbilical cord compression occurs when the umbilical cord is squeezed between the fetal body and the maternal pelvis or uterine wall during labor. This can cause variable decelerations, which are abrupt and irregular decreases in the fetal heart rate that vary in timing and duration.

Choice C rationale
Uteroplacental insufficiency is the cause of late decelerations. Uteroplacental insufficiency occurs when the blood flow and oxygen delivery to the placenta are reduced during labor. This can cause late decelerations, which are symmetrical decreases in the fetal heart rate that begin after the peak of the uterine contractions and return to baseline after the contractions end.

Choice D rationale
Maternal bradycardia is not the cause of late decelerations. Maternal bradycardia is a slow maternal heart rate that can be caused by various factors such as medication, hypotension, or vagal stimulation. Maternal bradycardia can affect the fetal heart rate, but it does not cause a specific pattern of decelerations.

Choice A rationale
Preparing the abdominal and perineal areas is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This may indicate placenta previa, a condition where the placenta covers the cervical opening, which can cause life-threatening hemorrhage for both the mother and the fetus. The priority is to stabilize the client's hemodynamic status and prevent hypovolemic shock.

Choice B rationale
Initiating IV access is the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This allows the nurse to administer fluids and blood products as needed to maintain the client's blood pressure and perfusion. It also provides a route for administering medications such as tocolytics, which can inhibit uterine contractions and reduce bleeding.

Choice C rationale
Inserting a Foley catheter is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This may increase the risk of infection and trauma to the lower urinary tract. It is also contraindicated in placenta previa, as it may dislodge the placenta and worsen the bleeding.

Choice D rationale
Administering oxygen via face mask is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This may be beneficial to improve the oxygenation of the mother and the fetus, but it does not address the underlying cause of the bleeding or the potential hypovolemia. Oxygen therapy should be initiated after securing IV access and fluid resuscitation.