A nurse is caring for a client who is nulliparous and in the first stage of labor. The last
internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?

A. A client with chronic obstructive pulmonary disease who needs guidance on incentive spirometry requires nursing judgment and education to ensure proper technique, so this task is best performed by a nurse.

B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires assessment and potential intervention by a nurse to address cardiac issues.

C. Assisting a client with toileting typically involves tasks such as transferring, positioning, and providing hygiene assistance, which can be safely delegated to an assistive personnel.

D. Providing a client who has awoken following a bronchoscopy with a drink involves assessing for the absence of nausea or vomiting and ensuring the client can swallow safely, which requires nursing judgment and should be performed by a nurse.

A. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.

B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.

C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.

D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.