A nurse is caring for a female client who is at 12 weeks of gestation in the prenatal clinic.

Exhibits

A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

The nurse should first address the fetal heart rate followed by the client's vaginal discharge.

WBC count rationale: A WBC count of 22,000/mm³ is significantly elevated above the normal range of 5,000 to 10,000/mm³, suggesting maternal infection such as chorioamnionitis. While this is clinically important, it is not the immediate first priority in acute obstetric care. Maternal infection must be managed, but fetal well-being is prioritized first because hypoxia or distress can occur rapidly and requires immediate recognition and intervention before laboratory abnormalities are addressed.

Maternal Blood Type rationale: The maternal blood type of O negative is clinically relevant for Rh incompatibility and the need for Rho(D) immune globulin administration. However, this is not an acute priority in the setting of preterm labor with rupture of membranes. Blood type considerations are important for long-term management but do not supersede the need to assess fetal well-being or evaluate vaginal discharge for evidence of amniotic fluid leakage or bleeding.

Fetal heart rate rationale: Fetal heart rate monitoring is the highest priority because it provides real-time information about fetal oxygenation and well-being. The normal baseline range is 110 to 160 beats per minute, and this client’s rate of 148/min is within normal limits. However, continuous monitoring is essential due to preterm labor, rupture of membranes, and maternal fever, all of which increase the risk of fetal distress. Therefore, fetal heart rate assessment is addressed first to ensure immediate recognition of hypoxia or compromise.

Respiratory rate rationale: The maternal respiratory rate of 18/min is within the normal adult range of 12 to 20/min. This finding does not indicate acute compromise and does not require urgent intervention. While maternal respiratory status is always monitored, it is not prioritized above fetal assessment or evaluation of vaginal discharge in this scenario. Thus, respiratory rate is stable and requires only routine monitoring, not immediate follow-up in the prioritization of care.

Blood pressure rationale: The maternal blood pressure of 112/59 mm Hg is within acceptable limits for pregnancy, as mild decreases in systemic vascular resistance are physiologic. Hypotension would be concerning if systolic <90 mm Hg or diastolic <50 mm Hg, but this value does not indicate shock or preeclampsia. Therefore, blood pressure is not prioritized over fetal monitoring or vaginal discharge assessment in this case. It remains stable and requires routine monitoring only.

Vaginal discharge rationale: Vaginal discharge is the next priority after fetal heart rate because the client has clear fluid with nitrazine positive, confirming premature rupture of membranes, along with mucous discharge and bleeding. These findings raise concern for infection, preterm labor progression, and placental complications. Evaluating vaginal discharge helps determine the presence of amniotic fluid, blood, or purulent material, guiding urgent interventions. Therefore, it is addressed immediately after fetal heart rate monitoring to prevent maternal and fetal complications.

Choice A rationale

Consistent crying is considered a late cue of hunger in a newborn. Crying, a complex physiological and behavioral response, requires a high expenditure of energy and is an indication that the newborn is already significantly distressed by hunger and needs to be fed immediately to avoid excessive agitation and difficulty latching.

Choice B rationale

The rooting reflex involves the newborn turning their head toward any stimulation of their cheek or mouth and opening their mouth, which is an innate physiological response critical for locating the nipple. This is a primary early hunger cue, indicating the newborn is ready and searching for a food source, initiating feeding efforts.

Choice C rationale

Sucking motions, such as rapid, repetitive sucking on the lips, tongue, or anything near the mouth, are direct early behavioral manifestations of the newborn's innate physiological need for nourishment. This action is a preparatory step for feeding, indicating readiness for oral intake and satiation of hunger.

Choice D rationale

Hand-to-mouth movements are a key early hunger cue, demonstrating the newborn's increasing drive to seek oral stimulation and food. This behavior is part of the newborn's reflexive self-soothing and exploratory repertoire, signaling a rising level of hunger before the onset of overt distress or crying.

Choice E rationale

The Babinski reflex is a normal neurological response in infants where the great toe extends upward and the other toes fan out when the sole of the foot is firmly stroked. It is a primitive reflex related to neurological development and is not an indicator of hunger or feeding readiness.