A nurse is using Naegele's rule to calculate the estimated due date of a client who reports that the first day of their last menstrual cycle was July 21st.
Which of the following should the nurse document as the client's expected due date?

Choice A rationale: A fundal height of 36 cm at 42 weeks gestation is concerning because fundal height should approximate gestational age in weeks ±2 cm. At 42 weeks, expected measurement is about 40–44 cm. A measurement of 36 cm suggests possible intrauterine growth restriction (IUGR) or oligohydramnios, both of which are complications associated with post-term pregnancy. This discrepancy requires further evaluation with ultrasound and fetal surveillance to ensure adequate growth and amniotic fluid volume.

Choice B rationale: A cervix that is closed and thick at 42 weeks gestation is not an immediate problem requiring intervention. Cervical ripening varies, and although induction may be considered at this gestational age, the cervix itself being closed is not pathologic. It simply indicates that spontaneous labor has not yet begun. This finding does not require urgent intervention but may guide decisions about induction methods such as prostaglandins or mechanical ripening.

Choice C rationale: A vertex presentation at +1 station is a favorable finding. Vertex is the optimal presentation for vaginal delivery, and +1 station indicates that the fetal head is descending into the pelvis. This is reassuring and does not require intervention. It suggests that the fetus is well-positioned for labor and delivery, and no abnormality is present in this assessment.

Choice D rationale: Clear to white mucus-like vaginal discharge is a normal physiologic finding in pregnancy, known as leukorrhea. It results from increased estrogen and cervical gland activity. This type of discharge is not associated with infection or rupture of membranes. Since it is expected and benign, it does not require intervention. Only abnormal discharges such as foul-smelling, green, or bloody secretions would warrant further evaluation.

Choice E rationale: A fetal heart rate of 150/min is within the normal baseline range of 110 to 160 beats per minute. This indicates adequate fetal oxygenation and no evidence of tachycardia or bradycardia. Since the rate is normal and reassuring, it does not require intervention. Continuous monitoring remains important, but this specific finding is not problematic.

Choice F rationale: A nonstress test that is nonreactive is concerning because it indicates that the fetus did not demonstrate adequate accelerations of heart rate with movement. A reactive NST requires at least two accelerations of 15 beats/min above baseline lasting 15 seconds within 20 minutes. A nonreactive result suggests possible fetal hypoxemia, sleep state, or neurologic compromise. This requires further evaluation with a contraction stress test or repeat biophysical profile.

Choice G rationale: A positive Group B Streptococcus culture is abnormal and requires intervention. GBS colonization increases the risk of neonatal sepsis, pneumonia, and meningitis if transmitted during delivery. Standard care is intrapartum prophylaxis with IV penicillin or ampicillin during labor. Since this client is GBS positive, the nurse must ensure that prophylactic antibiotics are administered at the onset of labor or rupture of membranes to prevent neonatal infection.

Choice H rationale: A biophysical profile score of 8/10 is considered reassuring. The BPP assesses fetal breathing, movement, tone, amniotic fluid volume, and NST. A score of 8 to 10 indicates normal fetal well-being, while 6 is equivocal and ≤4 is abnormal. Since this client’s score is 8, no immediate intervention is required. This is a reassuring finding and does not indicate fetal compromise.

Explanation

1. Moderate maternal bleeding
   • In a patient with HELLP and thrombocytopenia, bleeding suggests coagulopathy (DIC) or placental abruption. This is a serious worsening sign.
2. Ringing in ears (tinnitus)
   • Could be a side effect of magnesium sulfate toxicity or a neurological symptom of worsening preeclampsia. Either way, it’s concerning and not a sign of improvement.
3. Sharp, stabbing abdominal pain
   • RUQ/epigastric pain worsening into sharp pain raises concern for liver capsule distension or rupture (life-threatening complication of HELLP) or placental abruption. This is a red flag.
4. BP 180/100 mm Hg
   • Despite antihypertensive therapy, this is severe hypertension (≥160/110 mm Hg). Indicates poor control and worsening maternal risk.
5. FHR 80/min with absent variability
   • This is severe fetal bradycardia with no variability, indicating fetal hypoxia/distress. This is an obstetric emergency.
6. PT 12 seconds
   • Within normal range (11–13.5 sec). This suggests no current coagulopathy and is the only stable/improving finding.

Almost all findings point to worsening maternal and fetal condition, except for the PT which is stable. The nurse should immediately notify the provider, anticipate emergency delivery (likely induction or cesarean), and continue close monitoring for magnesium toxicity and bleeding complications.