Which of the following is the priority nursing action for a client at 33 weeks of gestation with a diagnosis of placenta previa?

Choice A reason:
Encouraging the client to empty her bladder every 2 hours is important because a full bladder can impede the progress of labor and increase the risk of bladder distension, which can lead to postpartum urinary retention or bladder atony. Additionally, a full bladder can obstruct the descent of the fetus and may contribute to labor dystocia. The normal range for urination frequency is typically every 3 to 4 hours, but during labor, more frequent emptying is beneficial.

Choice B reason:
While it may seem intuitive to remind the client to bear down with each contraction to aid in the delivery process, this is not recommended during the active phase of the first stage of labor. Bearing down, or pushing, is generally reserved for the second stage of labor when the cervix is fully dilated. Premature bearing down can lead to maternal exhaustion and increase the risk of cervical edema or lacerations.

Choice C reason:
Maintaining the client in the lithotomy position is not necessary during the active phase of the first stage of labor. This position is typically used during the delivery process in the second stage of labor. During the active phase, the client should be encouraged to find a comfortable position that facilitates labor progress, such as walking, squatting, or using a birthing ball.

Choice D reason:
Performing vaginal examinations frequently is not advised because it can increase the risk of introducing infections and can be uncomfortable for the client. Vaginal examinations should be performed judiciously to assess labor progress, typically not more than every 4 hours unless there is a specific indication to do so.

In the scenario provided, the Apgar score is calculated as follows:

- Appearance (skin color): The newborn has a pink trunk and head with bluish hands and feet, which scores 1 point.
- Pulse (heart rate): The heart rate is 130/min, which is above 100/min, so this scores 2 points.
- Grimace response (reflex irritability): The newborn cries in response to suctioning, which scores 2 points.
- Activity (muscle tone): The newborn has flexed extremities, which scores 2 points.
- Respiration (breathing effort): The cry is weak and slow, which scores 1 point.

Adding these up gives us a total Apgar score of 8 out of a possible 10 points.

Appearance (skin color): Normally, a score of 2 is given if the entire body is pink, 1 for pink body but blue extremities, and 0 if the whole body is pale or blue. The newborn's pink trunk and head with bluish hands and feet warrant a score of 1.

Pulse (heart rate): A score of 2 is given for a heart rate above 100/min, 1 for below 100/min, and 0 if there is no heartbeat. The newborn's heart rate of 130/min earns a score of 2.

Grimace response (reflex irritability): A score of 2 is given for a sneeze, cough, or vigorous cry, 1 for a grimace or feeble cry upon stimulation, and 0 for no response. The newborn's crying in response to suctioning gets a score of 2.

Activity (muscle tone): A score of 2 is given for active motion, 1 for some muscle tone and flexion of extremities, and 0 for limpness. The newborn's flexed extremities give a score of 2.

Respiration (breathing effort): A score of 2 is given for a good, strong cry, 1 for slow or irregular breathing, and 0 for no breathing. The newborn's weak and slow cry results in a score of 1.

The Apgar score helps the healthcare team decide if the newborn needs immediate medical care. A score of 7-10 is generally normal, 4-6 fairly low, and 3 and below critically low. An Apgar score of 8 indicates that the newborn is in good health but may need some medical attention, likely due to the weak and slow cry.