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:

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.

Choice A rationale

True labor is characterized by progressive cervical changes, including effacement (thinning) and dilation (opening) of the cervix. These changes are the most definitive signs that a woman is in true labor, as contractions can sometimes be Braxton Hicks contractions, which do not cause cervical change.

Choice B rationale

The station of the presenting part (how far down the baby's head is in the pelvis) can change during true labor as the baby descends. However, a single assessment of station does not definitively indicate true labor, as the baby may have been in a lower position prior to the onset of labor. Cervical changes are a more reliable indicator.

Choice C rationale

Rupture of the membranes (water breaking) can occur before or during true labor, but it is not always the first sign of labor. Some women experience contractions for a period before their membranes rupture, and some may not have their membranes rupture until late in labor or require artificial rupture. Therefore, it is not the most definitive sign of true labor.

Choice D rationale

A pattern of regular contractions that increase in frequency, duration, and intensity is a strong indication of true labor. However, some women may experience irregular contractions (Braxton Hicks) that can be mistaken for early labor. The key differentiator is whether these contractions are causing cervical change, making cervical assessment the most definitive sign.