When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage.
Which intervention(s) should the nurse implement? Select all that apply.

Choice A rationale

The scenario indicates that the client's contractions are increasing in frequency and intensity, and she reports significant pain, prompting a request for an epidural. The cervical exam shows she is 5 cm dilated and 90% effaced, with the baby at 0 station, which is typical for the active phase of labor. This is the appropriate time for an epidural, as pain management is often needed when contractions become more intense and dilation progresses. Clear amniotic fluid after artificial rupture of membranes also suggests no immediate complications.

Choice B rationale

Immediate cesarean section is generally reserved for situations of fetal distress or other obstetric emergencies. There is no mention of fetal heart rate abnormalities or other signs of distress in the scenario. While MS can complicate pregnancy, it does not automatically necessitate a cesarean section without specific indications. The decision for cesarean should be based on maternal or fetal indications not present in this case.

Choice C rationale

The instruction to start pushing is only appropriate during the second stage of labor when the cervix is fully dilated (10 cm). The client is 5 cm dilated, indicating she is still in the active phase of the first stage of labor. Encouraging pushing at this stage would be premature and could cause unnecessary exhaustion and potential harm to the cervix and fetus. Pushing is typically reserved for the final stage when the baby's head is crowning.

Choice D rationale

Administering an epidural and experiencing immediate pain relief aligns with the standard protocol for labor analgesia when requested by the client. Epidural anesthesia is a common and effective method for pain management during labor. This option respects the client's expressed need for pain relief and involves the healthcare provider in safely administering the epidural. Immediate relief from pain can help the client focus on labor progression and reduce stress.

Choice A rationale

Rechecking all vital signs, including core temperature, is essential to assess the client's overall status and identify any changes that may indicate a worsening condition or complications such as infection.

Choice B rationale

Applying oxygen via nasal prongs at 4 L/minute helps ensure adequate oxygenation, which is crucial for patients who may be experiencing postoperative complications, including fever and increased metabolic demand.

Choice C rationale

Continuing to monitor vital signs every hour is important to detect any further changes in the patient's condition and provide timely interventions if needed. Frequent monitoring allows for close observation of trends.

Choice D rationale

Exposing the client's extremities and applying ice packs to the axilla can help reduce fever by promoting heat loss. This intervention is beneficial in managing elevated body temperature and preventing complications associated with hyperthermia.