A nurse is admitting a client who is at 38 weeks of gestation and is in the active phase of the first stage of labor. Which of the following assessment findings is the first priority for the nurse to report to the provider?
Contractions lasting 2 minutes and with no rest between contractions.
Pressure on the perineum causing the client to have the desire to bear down.
Discharge consisting of clear fluid from the vagina.
Passage of a bloodtinged mucous plug.
The Correct Answer is A
Choice A: The first priority assessment finding to report to the provider is contractions lasting 2 minutes and with no rest between contractions. Prolonged contractions without adequate rest can lead to uterine hyperstimulation and fetal distress, potentially compromising the wellbeing of both the client and the baby. The provider needs to be informed immediately for further
evaluation and intervention.
Choice B: Pressure on the perineum and the desire to bear down indicate that the client is experiencing the urge to push, which is expected during the second stage of labor, not during the active phase of the first stage. It is not the first priority to report.
Choice C: Clear fluid discharge from the vagina can indicate rupture of membranes, but it is not an immediate concern unless the fluid is meconiumstained or there are other signs of fetal distress.
Choice D: Passage of a bloodtinged mucous plug (also known as "bloody show") is a common sign that labor is approaching, but it is not an immediate concern unless there are other signs of labor progression or complications. It is not the first priority to report.
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Related Questions
Correct Answer is C
Explanation
A. "This always happens by the end of the first trimester of pregnancy.": Quickening typically occurs later in pregnancy, not by the end of the first trimester.
B. "This will occur during the last trimester of pregnancy.": Quickening occurs much earlier than the last trimester.
C. "This usually happens between the fourth and fifth months of pregnancy.": Quickening, which is the first perception of fetal movements by the mother, generally occurs between 16 to 20 weeks of gestation.
D. "This will happen once the uterus begins to rise out of the pelvis.": Quickening does not directly correlate with the rising of the uterus out of the pelvis.
Correct Answer is C
Explanation
A: Administering glucocorticoids intramuscularly is indicated for enhancing fetal lung maturity in cases of anticipated preterm birth. However, the client is at 38 weeks of gestation, which is not considered preterm, and the elevated temperature is the main concern.
B: Preparing the client for an emergency cesarean section based solely on an elevated temperature is not an appropriate action. There may be other factors contributing to the temperature elevation, and further assessment is needed.
C: An elevated temperature during pregnancy can indicate infection, which is a concern when the client's membranes have ruptured (premature rupture of membranes or PROM). Before any
interventions are initiated, the nurse should assess the odor of the amniotic fluid as it can provide important information about possible infection. If the amniotic fluid has a foul odor or appears
cloudy, it may indicate infection and require prompt medical attention.
D: Rechecking the client's temperature in 4 hours is not the appropriate immediate action when an elevated temperature is observed, especially in a pregnant woman.
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