A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as -1. Which of the following interpretations of this finding should the nurse make?

The correct instruction is C. "Check the temperature of your baby's bath water with your hand."

Explanation:

A. "You can share your room with your baby for the next few weeks": This is a recommended practice. The American Academy of Pediatrics (AAP) recommends room-sharing without bed-sharing for at least the first six months and ideally for the first year of a baby's life. It promotes safe sleep and reduces the risk of Sudden Infant Death Syndrome (SIDS).

B. "Cover your baby with a light blanket while sleeping": This instruction is not recommended. The AAP advises against using loose bedding, including blankets, in the sleep environment to reduce the risk of SIDS. It is safer to use sleep sacks or wearable blankets if additional warmth is needed.

C. "Check the temperature of your baby's bath water with your hand": This is the correct instruction. It is essential to ensure that the bathwater is not too hot to prevent burns. Checking with the hand is a practical way to assess the water temperature before placing the baby in the bath.

D. "Your baby can nap in the car seat during the daytime": While napping in a car seat during travel is acceptable, it is not recommended for routine or prolonged sleep. The upright position in a car seat may compromise the baby's airway, increasing the risk of breathing difficulties. It's advised to transfer the baby to a flat, firm sleep surface for regular naps.

The correct answer is C. Continuous contraction lasting 2 min.

A. Pressure on the perineum causing the client to bear down is a common sign in the later stages of labor when the cervix is fully dilated. It is not typically a cause for immediate concern during the admission phase.

B. Expulsion of clear fluid from the vagina may be amniotic fluid, which can indicate rupture of membranes. While important to note, it is not as urgent as a prolonged contraction.

C. Continuous contraction lasting 2 min is a concerning finding and should be reported first.

A contraction lasting 2 minutes is excessively long and may lead to decreased uterine blood flow, affecting fetal oxygenation. It requires prompt attention from the healthcare provider.

D. Expulsion of a blood-tinged mucous plug, also known as the "bloody show," is a common occurrence in early labor and is not as urgent as the prolonged contraction.