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Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs late in pregnancy, around 38 to 40 weeks of gestation. It is associated with relief of pressure on the diaphragm but increased pelvic pressure. Since the client is only at 18 weeks of gestation, this finding cannot be interpreted as lightening.

Chloasma, also known as the "mask of pregnancy," is a hyperpigmentation of the skin that appears on the face due to hormonal changes during pregnancy. It is unrelated to fetal movement and would not be described as fluttering sensations in the abdomen. Therefore, this option does not apply to the client’s report.

Ballottement is a clinical technique used by healthcare providers during a pelvic examination to detect the presence of the fetus. It involves tapping the cervix to feel the fetus rebound within the amniotic fluid. It is not a subjective sensation experienced by the mother, so it does not match the client’s description of fluttering movements.

Removing the electronic fetal monitor once contractions are regular is incorrect. Oxytocin is a high-risk medication that can cause uterine tachysystole, fetal distress, and uterine rupture if not carefully monitored. Continuous electronic fetal monitoring is required throughout oxytocin administration to assess fetal heart rate patterns and contraction frequency. Discontinuing monitoring would place both mother and fetus at risk of undetected complications.

Oxytocin is not patient-controlled; it is administered via continuous IV infusion and titrated by the nurse according to the provider’s prescription and maternal-fetal response. Allowing the client to push a button to administer more medication would be unsafe, as oxytocin requires precise dosing and close monitoring to avoid overstimulation of the uterus.

Oxytocin does not prevent nausea and vomiting. Its primary purpose is to induce or augment labor by stimulating uterine contractions. Antiemetic medications are used to prevent nausea and vomiting, not oxytocin. Therefore, this statement is inaccurate and misleading.

Monitoring weight is important for tracking growth and nutritional status in an SGA newborn. However, weight changes occur gradually and do not represent an immediate, life-threatening concern. While necessary for long-term care, it is not the priority intervention in the immediate postnatal period.

Monitoring intake and output is important for assessing hydration status and renal function. While valuable, it is not as urgent as monitoring blood glucose levels, since hypoglycemia poses a more immediate threat to the newborn’s neurological stability and survival.

Monitoring axillary temperature is necessary because SGA newborns are prone to hypothermia due to decreased subcutaneous fat and impaired thermoregulation. However, hypoglycemia is a more critical and immediate risk. Temperature monitoring should be included in care but does not take precedence over glucose monitoring.

While infection is always a concern with repeated vaginal examinations, it is not the primary risk in placenta previa. The most immediate and critical danger is hemorrhage due to disruption of the placenta. Infection risk is secondary and does not explain why internal exams are specifically avoided in this condition.

Rupture of membranes can occur with vaginal examinations, but this is not the primary concern in placenta previa. Membrane rupture alone does not pose the same immediate threat as hemorrhage. The placenta’s location over the cervical os makes bleeding the most urgent risk.

Preterm labor can sometimes be triggered by vaginal manipulation, but this is not the primary reason internal examinations are avoided in placenta previa. The risk of profound bleeding is far more significant and immediate compared to the possibility of initiating contractions.

Coarse hair growth is not typical in anorexia nervosa. Instead, clients often develop fine, downy hair called lanugo as a compensatory mechanism to maintain body heat due to severe fat and muscle loss. Coarse hair growth would be more associated with endocrine disorders such as hyperandrogenism, not anorexia nervosa.

Tachycardia is not expected in anorexia nervosa. In fact, bradycardia is more common due to malnutrition, electrolyte imbalances, and decreased metabolic activity. The body slows down cardiovascular function to conserve energy, so tachycardia would not be a typical finding.

Warm, flushed extremities are not characteristic of anorexia nervosa. Clients with anorexia often present with cold extremities due to poor circulation, decreased subcutaneous fat, and hypothermia. Flushed extremities would suggest increased perfusion, which is inconsistent with the malnourished state.

Simply observing the parents’ feeding techniques without providing feedback is not appropriate. Failure to thrive often results from inadequate feeding practices, poor recognition of hunger cues, or psychosocial issues. Passive observation does not help parents learn or improve their skills. The nurse’s role is to provide education and support, not to remain silent when interventions are needed.

Feeding the infant while hospitalized to give parents a break may provide temporary relief but does not address the underlying issue. The parents must learn effective feeding techniques to continue care at home. If the nurse assumes responsibility for feeding, the parents miss the opportunity to gain confidence and skills, which perpetuates the problem after discharge.

Encouraging parents to rock their infant during and after feeding promotes bonding and comfort but does not directly address the feeding difficulties associated with failure to thrive. While rocking can soothe the infant, it does not improve nutritional intake or parental recognition of hunger cues. This is supportive but not the most appropriate intervention.

Massaging the posterior lower legs is contraindicated in clients at risk for thromboembolic disease. If a clot is present, massage can dislodge it, leading to a pulmonary embolism, which is life-threatening. This intervention increases risk rather than preventing complications.

Placing pillows under the knees can impede venous return by compressing blood vessels, increasing the risk of clot formation. This position promotes stasis in the lower extremities, which is dangerous for a client with thromboembolic disease.

Applying warm, moist heat to the lower extremities may provide comfort but does not prevent thromboembolic complications. Heat can dilate blood vessels and increase circulation locally, but it is not a substitute for ambulation. Additionally, if a clot is present, heat may worsen inflammation.

Initiating pushing is inappropriate in the presence of suspected placenta previa. Placenta previa occurs when the placenta covers the cervical os, either partially or completely. Pushing would increase intrauterine pressure and risk catastrophic hemorrhage. Labor should not be allowed to progress vaginally in placenta previa because the fetus cannot safely pass through the cervix without causing maternal and fetal compromise.

Performing a cervical examination is contraindicated in placenta previa. A vaginal exam can disrupt the placental attachment and cause massive hemorrhage. Diagnosis of placenta previa is made by ultrasound, not by manual examination. Attempting to check cervical dilation in this situation would place the client at immediate risk.

Magnesium sulfate infusion is used primarily for seizure prophylaxis in clients with preeclampsia or for neuroprotection in preterm labor. It does not treat placenta previa or hemorrhage. Administering magnesium sulfate would not address the underlying problem and is not appropriate in this scenario.

Early decelerations are gradual decreases in fetal heart rate that mirror uterine contractions. They are caused by fetal head compression and are considered benign, not associated with fetal distress or cord problems. They are expected during labor and do not indicate pathology.

Late decelerations occur after the peak of a contraction and are associated with uteroplacental insufficiency, not cord compression. They indicate impaired oxygen exchange between mother and fetus, often due to maternal hypotension, uterine hyperstimulation, or placental dysfunction. While serious, they are not linked to cord problems.

Accelerations are transient increases in fetal heart rate and are considered reassuring signs of fetal well-being. They indicate adequate oxygenation and intact neurologic response. Accelerations are not associated with cord compression or fetal compromise.

Telling the client “At least you know you have a healthy baby” dismisses her feelings and focuses only on the outcome. While the baby’s health is important, this response minimizes the client’s disappointment and does not provide emotional support. It can make the client feel unheard and invalidated.

Suggesting that the client can resume sexual relations sooner than after a vaginal birth is inaccurate and inappropriate. Cesarean birth involves abdominal surgery, which requires significant healing time. Recovery is not faster than vaginal delivery, and this response does not address the client’s emotional needs.