A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

The Apgar s core is a s coring s ys tem doctors and nurs es us e to as s es s newborns after they’re born. The Apgar s coring s ys tem is divided into five categories : Activity, Puls e, Grimace, Appearance, and Res piration. Each category receives a s core of 0 to 2 points 1.

Bas ed on the information you provided, the newborn’s 1-min Apgar s core would be calculated as follows :

• Activity: s ome flexion of extremities = 1 point

• Puls e: heart rate 110/ min = 2 points

• Grimace: grimace in res pons e to s uctioning of the nares = 1 point

• Appearance: body pink in color with blue extremities = 1 point

• Res piration: s low, weak cry = 1 point

Adding up the points for each category, the newborn’s 1-min Apgar s core would be 6.

Choice A rationale :

Prepare for cesarean birth. The nurse should consider preparing for a cesarean birth as the client is at 39 weeks of gestation and has heavy vaginal bleeding. Heavy vaginal bleeding during pregnancy could indicate an emergency situation such as placental abruption or placenta previa, both of which can be life-threatening for the mother and the baby. In such cases, an emergency cesarean birth might be necessary to ensure the safety of both the client and the baby. Promptly preparing for the procedure will help expedite the process and prevent any delays in providing necessary medical care.

Choice B rationale

Initiate an IV infusion of magnesium sulfate. Magnesium sulfate is not indicated in this situation. Magnesium sulfate is commonly used in obstetrics, particularly in the management of preeclampsia and eclampsia to prevent seizures. However, the client's heavy vaginal bleeding suggests a different issue and magnesium sulfate would not address the underlying cause. Instead, the focus should be on identifying and managing the cause of the bleeding to ensure the best outcome for the client and the baby.

Choice C rationale

Administer antibiotics. Administering antibiotics is not the priority action in this scenario. Heavy vaginal bleeding in a pregnant client requires immediate attention to assess the cause and determine the appropriate course of action. While antibiotics may be necessary in some situations, they are not the first-line treatment for heavy vaginal bleeding during pregnancy. The nurse should focus on providing prompt and appropriate care to address the client's immediate needs.

Choice D rationale

Request the RN to perform a cervical examination. Performing a cervical examination may provide valuable information about the cause of the heavy vaginal bleeding. It can help determine if the bleeding is related to cervical changes, such as cervical dilation or effacement. The findings from the cervical examination, along with other assessments, will aid in making the most appropriate decisions regarding the client's care. However, it is not the only action that the nurse should take. In this critical situation, the nurse must prioritize immediate interventions to ensure the safety and well-being of the client and the baby.