A nurse is caring for a client who is in the first stage of labor.
The nurse observes the umbilical cord protruding from the vagina.
Which of the following actions should the nurse NOT perform?

Step 1 is 2800 grams × 2.5 mg/kg. 2800 grams × 2.5 mg/kg = 7000 mg/kg.

Step 2 is 7000 mg ÷ (1000 mg/kg). 7000 mg ÷ (1000 mg/kg) = 7 mg.

Final calculated answer: 7 mg.

Choice A rationale: Initiating continuous electronic fetal monitoring is essential to assess the fetal heart rate and detect any signs of fetal distress. Given the history of decreased fetal movements, it's crucial to monitor the baby's condition closely.

Choice B rationale: Administering magnesium sulfate is recommended for neuroprotection in preterm deliveries, particularly for pregnancies less than 32-34 weeks gestation. It helps reduce the risk of cerebral palsy in preterm infants.

Choice C rationale: Performing a sterile speculum exam is unnecessary since the rupture of membranes has already been confirmed through the presence of amniotic fluid pooling and positive ferning test results.

Choice D rationale: Preparing the client for an emergency C-section is not immediately necessary unless there are signs of fetal distress or other complications. The priority is to stabilize the client's condition and monitor both the mother and the baby.

Choice E rationale: Monitoring for signs of chorioamnionitis is crucial since the client presents with ruptured membranes. Chorioamnionitis is a potential infection that can occur with prolonged rupture of membranes, which can lead to maternal and fetal complications. Monitoring includes assessing for fever, uterine tenderness, and foul-smelling amniotic fluid.