A nurse is admitting a client who is at 39 weeks of gestation and who states, "My water broke on the way to the hospital.”. Which of the following actions should the nurse take first?

Choice A rationale

A transvaginal fetal Doppler probe is an internal device used early in pregnancy to confirm fetal viability or heart rate in the first trimester, not an appropriate method for continuous intrapartum monitoring in a full-term client with intact membranes.

Choice B rationale

The DeLee-Hillis fetoscope is an external acoustic device used for intermittent auscultation of the fetal heart rate, providing a listening assessment rather than the prescribed continuous electronic tracing required for this client.

Choice C rationale

An external ultrasound transducer monitor (or tocodynamometer for contractions) uses non-invasive Doppler technology placed on the client's abdomen to detect and continuously monitor the fetal heart rate and uterine contractions when membranes are intact, satisfying the continuous monitoring prescription without internal access.

Choice D rationale

An internal fetal scalp electrode (FSE) requires the rupture of membranes and sufficient cervical dilation for placement onto the fetal scalp to provide a precise electrocardiogram of the fetal heart, which is not applicable since the client's membranes are intact.

Choice A rationale

Newborns require substantial sleep for optimal growth and neurological development, often sleeping for 16 to 20 hours in a 24-hour period, though this varies. This is a normal physiologic finding, reflecting the rapid growth and high metabolic demands of infancy, and does not require immediate medical attention. The sleep is typically fragmented into short bouts.

Choice B rationale

Decreased urine output, specifically fewer than 6 to 8 wet diapers in 24 hours after the first few days of life, is a critical sign of dehydration and inadequate fluid intake, especially if the newborn is breastfed. This insufficient hydration can lead to hyperbilirubinemia, weight loss, and electrolyte imbalance, requiring prompt medical evaluation.

Choice C rationale

Newborn stools can normally be loose and frequent, especially in breastfed infants, who often pass stools several times a day. Stools in the first week progress from meconium to transitional to yellow, seedy, and loose, which is a normal finding and generally does not warrant contacting the provider unless signs of illness or diarrhea are present.

Choice D rationale

The umbilical cord stump usually dries and falls off within 1 to 3 weeks after birth due to a process of dry gangrene and separation. While most detach earlier, remaining attached after 1 week is still within the realm of normal variation and is not typically a cause for immediate concern unless signs of infection are present.