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:

Stimulate the infant to cry. While stimulating the infant to cry is a common practice to assess the newborn's respiratory function, it is not the first action the nurse should perform in this situation. The newborn may cry spontaneously or may require other interventions, such as clearing the respiratory tract, before crying.

Choice B rationale:

Clear the respiratory tract. Clearing the respiratory tract is the priority action in this scenario. It ensures that the airway is open and allows the infant to breathe effectively. This is crucial because newborns are at higher risk of respiratory distress after birth, and prompt action can prevent complications.

Choice C rationale:

Dry the infant off and cover the head. Drying the infant off and covering the head are important steps to prevent heat loss and maintain the newborn's body temperature. However, these actions can be delayed briefly until the respiratory tract is cleared, as the immediate focus should be on ensuring the infant's ability to breathe.

Choice D rationale:

Clamp the umbilical cord. Clamping the umbilical cord is a standard procedure after birth to prevent bleeding and infection. However, it is not the priority in this situation. The first step should be to ensure the newborn's airway is clear and they can breathe adequately.

Choice A rationale:

The nurse should report visual disturbances to the provider. Visual disturbances in a pregnant client could indicate potential complications such as preeclampsia or eclampsia. These conditions are characterized by high blood pressure and can be harmful to both the mother and the fetus. Reporting visual disturbances promptly allows the provider to assess the situation and take appropriate actions to ensure the safety of the client and the baby.

Choice B rationale:

The nurse should also report blood pressure changes to the provider. The client's blood pressure has increased significantly from 179/99 mm Hg to 170/101 mm Hg over a short period. High blood pressure during pregnancy can be indicative of preeclampsia, a serious condition that requires close monitoring and management to prevent complications. Reporting the blood pressure changes promptly allows the provider to evaluate the situation and intervene as needed to safeguard the client's well-being.

Choice F rationale:

The nurse should report the fetal heart rate to the provider. Monitoring the fetal heart rate is crucial in prenatal care as it helps assess the well-being of the baby. Any abnormality in the fetal heart rate could indicate fetal distress or other complications. Promptly reporting any concerning changes in the fetal heart rate enables the provider to take appropriate measures to ensure the health and safety of the baby. The other choices (C, D, and E) are not the most critical findings in this scenario. While respiratory rate (C), deep tendon reflexes (D), and weight (E) are important aspects to monitor during pregnancy, they do not raise immediate concerns for potential complications like visual disturbances, blood pressure changes, and fetal heart rate abnormalities mentioned above. Nonetheless, they should still be documented and monitored regularly as part of routine prenatal care.