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. Edema is a common early sign of compartment syndrome as increased pressure within the compartment impairs venous outflow, leading to swelling.

B. Shortness of breath is not typically associated with compartment syndrome but may indicate other respiratory or cardiac issues.

C. Petechiae are not typically associated with compartment syndrome but may occur in conditions such as thrombocytopenia or coagulopathy.

D. Change in mental status is not typically associated with compartment syndrome but may indicate other neurological issues.

A. Crepitus is a finding associated with subcutaneous emphysema or gas accumulation under the skin, typically not directly related to right ventricular heart failure.

B. Right ventricular heart failure can lead to increased pressure in the pulmonary artery, resulting in symptoms such as dyspnea, fatigue, and possibly right-sided heart murmurs.

C. Hepatosplenomegaly (enlargement of the liver and spleen) is more commonly associated with conditions such as liver cirrhosis, not specifically right ventricular heart failure.

D. Confusion is not typically associated with right ventricular heart failure unless there are complications such as hypoxemia or impaired cerebral perfusion.