The nurse is observing a parent holding a preterm infant. The infant is sneezing, yawning, and extending the arms and legs. What action by the nurse is best?

Choice A) Report of absent breast pain is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client does not have mastitis or engorgement. Mastitis is an infection of the breast tissue that causes pain, swelling, redness, and fever. Engorgement is a condition where the breasts become overfilled with milk, causing pain, hardness, and leakage. Both conditions are common in postpartum women who are breastfeeding, but they are not related to methylergonovine or uterine bleeding. Therefore, this response is irrelevant and inaccurate.

Choice B) Increase in lochia is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the medication was ineffective or that the client has a complication. Lochia is the vaginal discharge that consists of blood, mucus, and tissue from the uterus after childbirth. It usually lasts for about 4 to 6 weeks and gradually decreases in amount and color. Methylergonovine is a medication that helps to control uterine bleeding by improving the tone and contractions of the uterus. An increase in lochia may mean that methylergonovine did not work well or that the client has a problem such as retained placenta, infection, or subinvolution. Therefore, this response is opposite and inaccurate.

Choice C) Increase in blood pressure is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client has a side effect or a risk factor. Blood pressure is the force of blood against the walls of the arteries. It is measured by two numbers: systolic (the pressure when the heart beats) and diastolic (the pressure when the heart rests). The normal range for blood pressure is 120/80 mm Hg or lower. Methylergonovine is a medication that can cause vasoconstriction, which means narrowing of the blood vessels and increasing of the blood pressure. This can lead to complications such as hypertension, stroke, or heart attack. Therefore, this response is adverse and inaccurate.

Choice D) Fundus firm to palpation is correct because this is a finding that indicates that the medication was effective and that the client has a good outcome. The fundus is the upper part of the uterus that can be felt through the abdomen after childbirth. It should be firm, midline, and at or below the level of the navel. A firm fundus means that the uterus has contracted well and stopped bleeding. Methylergonovine is a medication that helps to achieve this by improving the tone and contractions of the uterus. Therefore, this response is positive and accurate.

Choice A) Monitor uterine contractions is incorrect because this is not the most urgent intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Uterine contractions can indicate labor or placental abruption, which are possible causes of bleeding in late pregnancy. However, they are not the only or the most reliable indicators of these conditions, as some women may have painless bleeding or contractions without bleeding. Moreover, monitoring uterine contractions does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion. Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.

Choice B) Assess fetal heart rate (FHR) and maternal vital signs is correct because this is the most important and essential intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Bleeding in late pregnancy can be caused by various conditions, such as placenta previa, placental abruption, uterine rupture, or vasa previa, which can compromise the blood supply and oxygen delivery to the mother and the fetus. Assessing FHR and maternal vital signs can help to determine the severity and cause of the bleeding, as well as guide further

interventions such as fluid resuscitation, oxygen therapy, blood transfusion, or emergency delivery. The normal FHR range for a fetus is 110 to 160 beats per minute, and it may vary with fetal activity or maternal position. The normal maternal vital signs are: blood pressure 120/80 mm Hg or lower, heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, and temperature 36.5°C to 37.5°C (97.7°F to 99.5°F). Any deviation from these ranges may indicate hypoxia, hypovolemia, shock, infection, or distress. Therefore, this intervention should be done as soon as possible for women who have bleeding in late pregnancy.

Choice c) Perform a venipuncture for hemoglobin and hematocrit levels is incorrect because this is not a priority intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Hemoglobin and hematocrit are blood tests that measure the amount of red blood cells and their percentage in the blood volume.

They can help to evaluate the extent of blood loss and the need for blood transfusion. However, they are not

immediate or accurate indicators of bleeding in late pregnancy, as they may take time to reflect the changes in blood volume or be affected by other factors such as hydration or hemodilution. Moreover, performing a venipuncture does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion.

Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.

Choice d) Place clean disposable pads to collect any drainage is incorrect because this is not a priority intervention for a pregnant woman who has experienced a bleeding episode in late pregnancy. Placing clean disposable pads can help to keep the perineal area clean and dry, as well as to estimate the amount and type of bleeding. However, it does not address the immediate needs of the mother and the fetus, such as oxygenation, circulation, and perfusion. Moreover, it does not provide any information about the cause or severity of the bleeding, as it may be affected by factors such as gravity or pooling. Therefore, this intervention should be done after assessing and stabilizing the vital signs and FHR.