A nurse is attending to an 8-year-old child diagnosed with acute rheumatic fever. What should be the nurse’s immediate priority assessment after admission?

Choice A rationale
Cervical dilation is a key sign that labor has begun. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a physical change that can be measured during a pelvic exam.
Choice B rationale
Pain above the umbilicus is not typically a sign of labor. During labor, contractions are usually felt as a tightening or cramping in the lower abdomen or back.
Choice C rationale
Brownish vaginal discharge can occur during pregnancy and is not necessarily a sign of labor. If the discharge is heavy, or accompanied by other symptoms such as pain or cramping, it should be evaluated by a healthcare provider.
Choice D rationale
The presence of amniotic fluid in the vaginal vault, also known as “water breaking,” can be a sign that labor is imminent. However, it does not confirm that labor has begun, as it can occur before the onset of contractions and cervical dilation.

Choice A rationale
While it’s true that some changes in the breast, such as dimpling or discharge, can occur with age, these are not normal and could be signs of a serious condition like breast cancer.
Therefore, this instruction should not be included in the pamphlet.
Choice B rationale
While using the palm of the hand to feel for lumps using a circular motion is a common method, it’s not the most effective. The pads of the three middle fingers should be used instead, as they are more sensitive to changes in the breast tissue.
Choice C rationale
This is the correct answer. Performing a breast self-exam in the shower with soapy hands is recommended because the soap helps your fingers glide smoothly over your skin, making it easier to feel for any lumps or changes.
Choice D rationale
While it’s true that women who have a menstrual cycle should perform a breast self-exam every month, the timing suggested here is not accurate. The best time to perform a breast self- exam is a few days after the menstrual period ends, when the breasts are less likely to be tender or swollen.