When performing a Non-Stress test, the nurse interprets the finding of two accelerations of the fetal heart rate of 15 beats per minute above the baseline rate of 135 beats per minute lasting for 15 seconds in 20 minutes.
This should be documented as:

Choice A rationale

While addressing the client's pain is important, the priority action should be to assess the underlying cause of the concerning vital signs before offering pain medication.

Choice B rationale

Positioning the client with one hip elevated is a measure used to relieve potential vena cava compression, but the low blood pressure warrants immediate attention and further evaluation before implementing this intervention.

Choice C rationale

Having the client void may be a helpful intervention in some labor situations, but the combination of a low maternal blood pressure and a high maternal heart rate requires immediate notification of the provider.

Choice D rationale

The client's low blood pressure (82/54 mm Hg) and elevated maternal heart rate (128/min) in the presence of contractions with a duration of 1 minute and a frequency of 3 minutes are concerning findings that warrant immediate notification of the provider for further evaluation and management. These vital signs could indicate maternal hypovolemia, dehydration, or other complications. .

The complication that poses the greatest risk for the client is hemorrhage as evidenced by their amount of lochia.

Rationale for correct answers

Postpartum hemorrhage (PPH) is a major concern when excessive lochia and a boggy uterus are present. The nurse’s assessment reveals a boggy fundus, which firmed with massage but then softened again, indicating uterine atony, a leading cause of PPH. Additionally, the saturation of the perineal pad with lochia rubra and small clots suggests ongoing bleeding that requires close monitoring.

Rationale for incorrect Response 1 options

• Infection: No fever (≥38°C or 100.4°F) or foul-smelling lochia, which would indicate postpartum endometritis.
• Thrombophlebitis: No calf pain, swelling, or localized tenderness suggesting deep vein thrombosis.
• Mastitis: Breasts are soft, warm, and tender but without redness or localized pain, making mastitis unlikely.

Rationale for incorrect Response 2 options

• Breast tenderness: Expected due to milk production, not indicative of infection or complications.
• Calf pain: No evidence of thrombophlebitis or deep vein thrombosis.
• Fever: Temperature is normal at 37.2°C, ruling out systemic infection.