A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

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.

Choice A rationale :

Vitamin K decreases the newborn's risk of jaundice. Rationale: This statement is incorrect. Vitamin K plays no direct role in reducing the risk of jaundice in newborns. Jaundice is primarily caused by the accumulation of bilirubin in the blood, which is a different issue than hemorrhagic disorders.

Choice B rationale

Vitamin K decreases the newborn's risk of healthcare-associated infections. Rationale: This statement is incorrect. Vitamin K is not related to reducing the risk of healthcare-associated infections. Its main function is related to blood clotting and preventing hemorrhagic disorders.

Choice C rationale

Vitamin K decreases the newborn's risk of hemorrhagic disorders. Rationale: This statement is correct. Vitamin K is essential for the production of clotting factors in the blood, which helps prevent bleeding or hemorrhagic disorders in newborns. Newborns are born with low levels of vitamin K, so administering a vitamin K injection at birth is a common practice to prevent potential bleeding issues.

Choice D rationale

Vitamin K decreases the newborn's risk of complications from the Hepatitis B vaccine. Rationale: This statement is incorrect. Vitamin K is not directly related to reducing the risk of complications from the Hepatitis B vaccine. The vaccine is designed to protect against Hepatitis B infection, and vitamin K is not involved in its efficacy or safety.