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False labor contractions, often called Braxton Hicks, are typically irregular and weak, do not increase in intensity or duration over time, and usually cease with walking or changing position. Importantly, false labor does not cause progressive changes in the cervix, meaning the dilation would not progress from 4 cm to 6 cm as described in this clinical scenario. This lack of cervical change differentiates it from true labor.

Placental abruption involves the premature separation of the placenta from the uterine wall, which usually presents with painful, firm, or rigid uterine tone and often vaginal bleeding. While the uterus is firm, the complete softening between contractions and progressive cervical change are classic signs of normal labor, not the sustained, often hypertonic, rigidity associated with a severe abruption.

Uterine tachysystole is defined as more than five contractions in a 10-minute period, averaged over 30 minutes, or a series of single contractions lasting longer than 2 minutes. The scenario describes contractions lasting 45 seconds with complete relaxation between, which is within the normal range for active true labor, and does not meet the criteria for tachysystole.

Braxton Hicks contractions are typically irregular in frequency, short in duration, and weak in intensity, often described as a mild tightening in the abdomen. They frequently disappear with ambulation or rest. The client's contractions, which are described as regular every 5 minutes, getting stronger, and intensifying with walking, do not align with the characteristics of Braxton Hicks.

The latent phase of labor is the period from the beginning of true labor until 6 cm of cervical dilation. Since the client is 3 cm dilated with 80 percent effacement and experiencing regular, increasing contractions, she is definitively in the latent phase of true labor, not false labor, as her symptoms are progressive and regular.

False labor contractions are irregular and do not lead to cervical change. Key indicators of false labor are contractions that lessen or cease with activity and are felt mainly in the lower abdomen or groin. The client's contractions are regular and increased in intensity with walking, which is a classic differentiator for true labor.

While urinary frequency can be a sign of a urinary tract infection (UTI), a UTI would also typically present with other symptoms such as dysuria (painful urination), hematuria, or fever, which are not mentioned. The concurrent relief of shortness of breath strongly correlates the bladder pressure with the mechanical descent of the fetus, or lightening.

Lightening is a normal physiologic event of late pregnancy, indicating the body is preparing for labor, but it does not mandate immediate hospitalization. The nurse should provide reassurance and education, advising the client to seek care when true labor contractions begin or if membranes rupture.

Avoiding ambulation is not indicated for lightening. Walking can actually be beneficial, as it encourages the fetal head to engage further, and it does not increase the risk for preterm labor at 37 weeks gestation, which is considered full-term in current definitions. Lightening is a normal process, and activity is generally encouraged.

Uterine atony is a condition where the uterus fails to contract adequately after childbirth, leading to postpartum hemorrhage. This complication is not directly related to prolonged rupture of membranes or signs of infection, which are characterized by fever, foul-smelling amniotic fluid, and maternal tachycardia. Uterine atony is typically assessed by palpating a soft, boggy fundus, which is a sign of bleeding risk rather than ascending infection.

Placental abruption is the premature separation of the placenta from the uterine wall before delivery, usually causing painful vaginal bleeding and changes in fetal heart rate tracing. While serious, this condition is not indicated by the triad of prolonged rupture of membranes, maternal fever (100.8°F), and foul-smelling amniotic fluid, which strongly suggest an intra-amniotic infection.

Fetal acidosis, often determined by a fetal scalp pH < 7.20, indicates severe fetal distress resulting from interrupted oxygenation, potentially due to umbilical cord compression or placental insufficiency. Although infection can eventually lead to fetal distress, the primary clinical signs (fever, foul odor) point specifically to the infectious process of chorioamnionitis as the initial, most probable complication.

A cervical tear occurring during birth is typically characterized by a steady trickle or frank hemorrhage of bright red blood after delivery, even with a firm uterus. The signs noted, including the fundus becoming globular and the gush of dark red blood, are classic, sequential physiological signs indicating the separation of the placenta from the uterine wall.

Clots forming in the upper uterine segment might contribute to a boggy, displaced uterus if they lead to uterine atony and hemorrhage, but they are not the cause of the described signs. The specific changes observed—globular fundus and gush of blood—are reliable physiological markers signaling the detachment of the placenta, preparing it for delivery.

Hemorrhage, particularly postpartum hemorrhage, is generally defined as blood loss > 500 mL following a vaginal birth. While the gush of blood can be significant, the preceding globular change in the fundus confirms the stage of placental separation, which is a normal finding, not a definitive indication that the client is experiencing a life-threatening hemorrhage at this precise moment.

A client 40 weeks in early labor tells the nurse she feels wet.
The nurse observes spontaneous rupture of membranes with clear fluid.

A client 40 weeks in early labor tells the nurse she feels wet.
The nurse observes spontaneous rupture of membranes with clear fluid.

A client 40 weeks in early labor tells the nurse she feels wet.
The nurse observes spontaneous rupture of membranes with clear fluid.

While notifying the provider is an important step in managing postpartum hemorrhage, the nurse's first, most immediate action is to attempt to stop or slow the blood loss. Manual massage of the fundus stimulates uterine muscle contraction, which compresses the open blood vessels at the placental site and reduces bleeding.

Preparing for surgery is a management option for intractable hemorrhage that does not respond to initial, less invasive measures like massage and uterotonic drugs. It is not the immediate, first-line action; immediate intervention focuses on stimulating uterine contraction through manual fundal massage.

Administering intravenous Pitocin (oxytocin) is the first-line pharmacologic intervention for uterine atony, but it is typically ordered concurrent with or immediately following fundal massage. The physical act of fundal massage is the most immediate, non-invasive first step to address the lack of uterine tone and reduce acute blood loss.

Pitocin (synthetic oxytocin) is a powerful uterotonic drug that is used after placental delivery to prevent postpartum hemorrhage. Its action is to stimulate vigorous, sustained contractions of the uterine muscle cells, thereby clamping down on the bleeding blood vessels within the placental insertion site, not to promote progressive cervical change, which is a function of natural labor forces and cervical ripening agents.

Oxytocin's primary role in the postpartum period is stimulating uterine contraction; it has no significant analgesic or pain-relieving properties. Pain relief after birth is managed with analgesics or non-pharmacological methods, as Pitocin administration can actually cause painful cramping as the uterus contracts to prevent bleeding.

Pitocin stimulates contractions, directly opposing rest and relaxation of the uterus. The goal of administering Pitocin immediately after delivery of the placenta is to cause powerful, sustained uterine contractions (tetany) to achieve hemostasis by physically squeezing the myometrial arteries that supplied the placenta, preventing excessive blood loss.

Magnesium Sulfate is an anticonvulsant and tocolytic agent primarily used to prevent seizures in preeclampsia or for fetal neuroprotection, and occasionally to relax the uterus for an arrest of labor. It is not indicated for acute fetal bradycardia or variable decelerations resulting from potential cord compression. Administering this medication would delay the critical assessment and intervention required to stabilize the fetal heart rate, which is the immediate clinical priority in this emergency situation.

Checking maternal vital signs is an important component of the initial assessment, as maternal hypotension or fever could cause fetal distress. However, in the setting of spontaneous rupture of membranes followed immediately by severe, unresolving fetal bradycardia (70 bpm), the highest priority is to rule out umbilical cord prolapse, which requires immediate intervention. The vital sign check can be performed by another staff member while the nurse performs the essential vaginal examination.

Oxytocin is a synthetic uterotonic hormone used to induce or augment labor by stimulating uterine contractions. Increasing its infusion rate would intensify uterine activity, potentially worsening the already compromised fetal oxygenation due to cord compression. Stronger contractions would further decrease blood flow through the intervillous spaces and increase pressure on a potentially prolapsed or compressed cord, escalating the fetal distress rather than resolving it.