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?

Choice A rationale:

Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labour, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.

Choice B rationale:

Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.

Choice C rationale:

Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labour has commenced. Panting is not necessary at this point.

Choice D rationale:

The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.

Choice A rationale:

Excessive uterine enlargement. Rationale: The nurse should monitor the client for excessive uterine enlargement, as a hydatidiform mole is a rare condition in pregnancy where abnormal placental tissue forms instead of a fetus. This abnormal growth can lead to uterine enlargement beyond the expected size for gestational age.

Choice B rationale:

Rapidly dropping human chorionic gonadotropin (hCG) levels. Rationale: The nurse should also monitor the client's hCG levels. In a normal pregnancy, hCG levels typically rise steadily during the early stages. However, in the case of a hydatidiform mole, hCG levels may either plateau or drop rapidly due to the abnormal placental growth.

Choice C rationale:

Fetal heart rate irregularities. Rationale: Although a hydatidiform mole does not involve a viable fetus, the nurse should still assess for fetal heart rate irregularities. In some rare cases, the presence of abnormal placental tissue can cause confusion in the diagnosis, and there may be coexisting fetal development. Fetal heart rate irregularities may indicate potential complications.

Choice D rationale:

Whitish vaginal discharge. Rationale: Whitish vaginal discharge is not typically associated with a hydatidiform mole. Instead, this finding is more commonly seen in other vaginal infections or conditions unrelated to a molar pregnancy. The nurse should be cautious not to misinterpret this symptom as a definitive sign of a hydatidiform mole.