A nurse is performing a physical examination of a term newborn upon admission to the nursery.
In which order should the nurse perform the following assessments?

A. Maternal vital signs are important for overall assessment, but they do not provide immediate information about fetal descent or imminent birth. The symptoms described are more suggestive of rapid labor progression rather than a maternal systemic issue.

B. Fetal heart rate assessment is essential in labor, but the client’s urge to defecate and nausea strongly suggests fetal descent and cervical dilation. Before focusing on fetal tracing interpretation, the nurse should confirm labor progression to anticipate delivery.

C. Meconium-stained discharge may occur in labor, but assessing discharge does not address the most likely cause of the client’s symptoms. The priority is to determine cervical dilation and fetal station.

D. An urge to bear down, nausea, and rectal pressure during a contraction are classic signs of advanced labor and fetal descent. A vaginal examination is the priority to assess cervical dilation and prevent inadvertent delivery without preparation.

Choice A rationale

A client at 12 weeks of gestation not feeling fetal movement is expected. Fetal movement, or quickening, typically begins between 16 and 20 weeks of gestation for primigravidas and earlier for multigravidas. At 12 weeks, the fetus is still small and movements are not usually strong enough to be consistently perceived by the mother, thus this finding is not immediately concerning.

Choice B rationale

A fetal heart rate (FHR) of 160/min at 28 weeks of gestation is within the normal range, which is typically 110-160 beats/min. A normal FHR indicates adequate fetal oxygenation and well-being. Therefore, this finding does not suggest an emergent situation requiring immediate provider assessment.

Choice C rationale

Deep tendon reflexes (DTRs) graded as 2+ are considered normal. This grading indicates an average, brisk reflex response. Abnormal DTRs, such as hyperreflexia (3+ or 4+), can be indicative of preeclampsia, but a 2+ finding is physiological and does not warrant immediate concern.

Choice D rationale

Blurred vision in a client at 36 weeks of gestation can be a symptom of preeclampsia, a serious hypertensive disorder of pregnancy. This condition can lead to severe complications such as eclampsia, placental abruption, or HELLP syndrome, requiring immediate medical evaluation and intervention to prevent adverse maternal and fetal outcomes.