A nurse is caring for a client who is having a vacuum-assisted birth.
Which of the following actions should the nurse take?

Choice A rationale: A fundal height of 36 cm at 42 weeks gestation is concerning because fundal height should approximate gestational age in weeks ±2 cm. At 42 weeks, expected measurement is about 40–44 cm. A measurement of 36 cm suggests possible intrauterine growth restriction (IUGR) or oligohydramnios, both of which are complications associated with post-term pregnancy. This discrepancy requires further evaluation with ultrasound and fetal surveillance to ensure adequate growth and amniotic fluid volume.

Choice B rationale: A cervix that is closed and thick at 42 weeks gestation is not an immediate problem requiring intervention. Cervical ripening varies, and although induction may be considered at this gestational age, the cervix itself being closed is not pathologic. It simply indicates that spontaneous labor has not yet begun. This finding does not require urgent intervention but may guide decisions about induction methods such as prostaglandins or mechanical ripening.

Choice C rationale: A vertex presentation at +1 station is a favorable finding. Vertex is the optimal presentation for vaginal delivery, and +1 station indicates that the fetal head is descending into the pelvis. This is reassuring and does not require intervention. It suggests that the fetus is well-positioned for labor and delivery, and no abnormality is present in this assessment.

Choice D rationale: Clear to white mucus-like vaginal discharge is a normal physiologic finding in pregnancy, known as leukorrhea. It results from increased estrogen and cervical gland activity. This type of discharge is not associated with infection or rupture of membranes. Since it is expected and benign, it does not require intervention. Only abnormal discharges such as foul-smelling, green, or bloody secretions would warrant further evaluation.

Choice E rationale: A fetal heart rate of 150/min is within the normal baseline range of 110 to 160 beats per minute. This indicates adequate fetal oxygenation and no evidence of tachycardia or bradycardia. Since the rate is normal and reassuring, it does not require intervention. Continuous monitoring remains important, but this specific finding is not problematic.

Choice F rationale: A nonstress test that is nonreactive is concerning because it indicates that the fetus did not demonstrate adequate accelerations of heart rate with movement. A reactive NST requires at least two accelerations of 15 beats/min above baseline lasting 15 seconds within 20 minutes. A nonreactive result suggests possible fetal hypoxemia, sleep state, or neurologic compromise. This requires further evaluation with a contraction stress test or repeat biophysical profile.

Choice G rationale: A positive Group B Streptococcus culture is abnormal and requires intervention. GBS colonization increases the risk of neonatal sepsis, pneumonia, and meningitis if transmitted during delivery. Standard care is intrapartum prophylaxis with IV penicillin or ampicillin during labor. Since this client is GBS positive, the nurse must ensure that prophylactic antibiotics are administered at the onset of labor or rupture of membranes to prevent neonatal infection.

Choice H rationale: A biophysical profile score of 8/10 is considered reassuring. The BPP assesses fetal breathing, movement, tone, amniotic fluid volume, and NST. A score of 8 to 10 indicates normal fetal well-being, while 6 is equivocal and ≤4 is abnormal. Since this client’s score is 8, no immediate intervention is required. This is a reassuring finding and does not indicate fetal compromise.

Choice A rationale

True labor contractions persist and often intensify with activity, such as walking, because physical exertion promotes the release of oxytocin. In contrast, Braxton Hicks or false labor contractions typically diminish or cease with ambulation. Therefore, contractions persisting with walking indicate the cervical changes characteristic of progression into the active phase of labor.

Choice B rationale

Urinary frequency is a common discomfort throughout the third trimester of pregnancy due to the pressure of the enlarged uterus on the bladder. While present, it is not a specific indicator of the progression of labor from the latent to the active phase, which is characterized by measurable changes in cervical dilation and effacement.

Choice C rationale

Increased blood-tinged vaginal mucus, known as "bloody show," results from the cervical capillaries breaking as the cervix effaces and dilates. While this indicates cervical change, the most definitive sign of labor progression is a change in the frequency, duration, and intensity of contractions coupled with measurable descent or cervical dilation increase.

Choice D rationale

The station is the relationship of the presenting part to the ischial spines (zero station). The client's initial station was -1 cm. A change to -3 cm station indicates the fetus has moved up and away from the ischial spines, which signifies regression, or higher negative numbers, in the engagement, not the desired progression into the maternal pelvis.