Labor And Postpartum Client Monitoring - NCLEX-PN

Resting tone is soft/relaxed by palpation between contractions. Soft tone ensures adequate placental reperfusion between contractions, preventing fetal distress from hyperstimulation.

More than 5 contractions in 10 minutes (averaged over 30). Excessive contractions reduce intervillous blood flow, potentially causing fetal hypoxia if prolonged.

Nonrebreather mask at 10 L/min. This method provides high-flow oxygen to enhance maternal hemoglobin saturation and fetal oxygen transfer across the placenta.

Stop oxytocin infusion. Discontinuing oxytocin reduces excessive uterine activity, allowing fetal recovery from compromised oxygenation.

Reposition client to lateral side-lying. Changing position relieves inferior vena cava compression, improving maternal cardiac output and uteroplacental perfusion.

Abrupt decel with variable timing; often cord compression. These decelerations are caused by transient umbilical cord compression, leading to abrupt drops unrelated to contraction timing.

Decel mirrors contraction; nadir at contraction peak. This benign pattern results from vagal stimulation due to fetal head compression during contractions.

Undetectable amplitude range around baseline. Absence of fluctuations may signal fetal acidosis, CNS depression, or medication effects, warranting urgent evaluation.

Amplitude range 6–25 bpm around baseline. This variability level is reassuring, reflecting intact fetal central nervous system and autonomic regulation.

Decel begins after contraction starts; nadir after peak. This pattern indicates uteroplacental insufficiency, where decreased oxygen delivery during contractions causes delayed fetal heart rate recovery.

Baseline FHR >160 bpm for at least 10 minutes. Elevated rate often indicates maternal fever, infection, or fetal stress, classified as a Category II feature.

Baseline FHR <110 bpm for at least 10 minutes. Persistent low rate suggests potential fetal hypoxia, acidosis, or congenital heart issues requiring intervention.

Normal FHR baseline is 110–160 bpm. This range reflects fetal well-being per NICHD guidelines, indicating adequate oxygenation and autonomic function during labor.

Unilateral leg pain, warmth, swelling, and tenderness. These localized signs reflect venous inflammation and thrombosis, heightened by postpartum hypercoagulability.

Fever after 24 hours with uterine tenderness and foul lochia. These symptoms indicate bacterial infection of the endometrium, often from ascending pathogens post-delivery.

May be up to 38°C (100.4°F) in first 24 hours. Mild elevation results from labor exertion and dehydration, considered physiologic if resolving without infection signs.

Assist the client to void (suspect bladder distention). Deviation suggests bladder fullness displacing the uterus, impeding involution and increasing bleeding risk.

Saturated perineal pad in 1 hour or less. Rapid saturation signals excessive blood loss, often from uterine atony, requiring immediate intervention to prevent shock.

Perform firm fundal massage. Massage stimulates uterine contraction, expelling clots and reducing hemorrhage risk from atony.

At or near the umbilicus, firm and midline. Post-delivery involution places the fundus at this level, with firmness indicating effective contraction to control bleeding.

Lochia rubra: dark red, bloody flow. Initial lochia consists of blood and decidua from uterine shedding, transitioning to serosa after 3-4 days.

Assess fetal heart rate for cord prolapse. Rupture increases risk of cord descent and compression, necessitating prompt FHR assessment for bradycardia.

Nitrazine or ferning test of vaginal fluid. Nitrazine detects alkaline amniotic fluid via pH change, while ferning shows characteristic crystallization under microscopy.

Hypotension is a common adverse effect. Epidural-induced sympathectomy causes vasodilation, reducing preload and blood pressure in laboring clients.