A delirious client is admitted to the hospital in labor.
She has had no prenatal care and vials of crack cocaine are found in her pockets.
The nurse monitors this client carefully for which of the following intrapartum complications?

Choice A rationale

While maternal lacerations are a risk during childbirth, they are not the greatest risk in cases of fetal dystocia. The focus is primarily on fetal wellbeing.

Choice B rationale

Fetal injury such as bruising can occur with dystocia, but the primary concern is the potential for severe, life-threatening complications.

Choice C rationale

Neonatal asphyxia related to prolonged labor is the greatest risk with fetal dystocia. Prolonged labor can lead to decreased oxygen supply to the fetus, causing asphyxia and potential brain injury.

Choice D rationale

Increased consideration for a cesarean delivery is a possible outcome of fetal dystocia, but it is a management decision rather than a direct risk to the baby’s immediate health.

Choice A rationale

Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.

Choice B rationale

Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.

Choice C rationale

Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.

Choice D rationale

Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.