A nurse is assisting to collect data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.)

Choice A reason:

This statement is not appropriate because it does not provide any information or education to the client who wants to know about VBAC. It also implies that the nurse does not have any knowledge or expertise on the topic, which may undermine the client's trust and confidence in the nurse.

Choice B reason:

This statement is not appropriate because it is not evidence-based and may discourage the client from considering VBAC as a possible option. According to research, VBAC is associated with fewer complications than an elective repeat C-section for many women who had prior

cesarean deliveries. A repeat C-section also carries risks such as infection, bleeding, injury to organs, and placental problems in future pregnancies.

Choice C reason:

This statement is appropriate because it is accurate and informative. The type of uterine incision used for the prior C-section is one of the most important factors that determine the eligibility and success of VBAC. A low transverse or low vertical incision is usually compatible with VBAC, while a high vertical (classical) incision is not recommended due to the risk of uterine rupture.

Choice D reason:

This statement is not appropriate because it dismisses the client's concern and does not address their question. It also implies that the nurse does not respect the client's autonomy and right to make informed decisions about their care. The client may benefit from learning about VBAC early in their pregnancy so that they can weigh the pros and cons and discuss their preferences with their provider.

Choice A reason:

Administering methylergometrine to the client is not the first action the nurse should take. Methylergometrine is a medication that stimulates uterine contractions and can help reduce postpartum bleeding. However, it can also cause hypertension and should be used with caution in clients with high blood pressure. Furthermore, the nurse should first identify and address the cause of the boggy and deviated fundus before giving any medication.

Choice B reason:

Assisting the client to void is the first action the nurse should take. A full bladder can displace the uterus and prevent it from contracting properly, leading to uterine atony and bleeding.

The nurse should help the client empty her bladder by encouraging her to use the bathroom, providing privacy, running water, or using a bedpan. This can help the uterus return to its normal position and tone.

Choice C reason:

Inserting an indwelling urinary catheter is not the first action the nurse should take. A urinary catheter can be used to drain the bladder if the client is unable to void or has a large amount of residual urine. However, it can also increase the risk of infection and trauma to the urethra

and bladder. The nurse should first try noninvasive methods to help the client void, such as those mentioned in choice B.

Choice D reason:

Obtaining a stat hemoglobin level is not the first action the nurse should take. A hemoglobin level can indicate the extent of blood loss and the need for transfusion or other interventions. However, it is not a priority over restoring uterine tone and preventing further bleeding. The nurse should first assist the client to void and then massage the fundus if it remains boggy.