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Apply petroleum jelly to the cord stump: This is not recommended. Applying petroleum jelly can create a moist environment, which can delay the drying and falling off of the cord stump.

Wash the cord daily with mild soap and water: This is not necessary. The cord stump should be kept dry to promote healing and prevent infection. Washing it daily with soap and water can delay the drying process.

Cover the cord with the diaper: This is not recommended. The diaper should be folded down so that the cord stump is exposed to air, which helps it dry out and fall off. Covering the cord stump with the diaper can keep it moist and delay the healing process. It can also expose the stump to urine and feces, which can lead to infection.

Administer oxygen using a non-rebreather mask: This action might be appropriate if the fetus shows signs of distress, but it’s not the first action the nurse should take. The first action should be to change the mother’s position to improve blood flow to the fetus.

Increase the rate of maintenance IV infusion: This action might be appropriate in some situations, but it’s not the first action the nurse should take. The first action should be to change the mother’s position to improve blood flow to the fetus.

Elevate the client’s legs: This action is not likely to improve the fetal heart rate pattern. The first action should be to change the mother’s position to improve blood flow to the fetus.

It increases the fetal heart rate: Betamethasone does not directly increase the fetal heart rate. Its primary function is to accelerate lung maturity and production of surfactant, a substance that prevents the lungs from collapsing.

It halts cervical dilation: Betamethasone is not used to halt cervical dilation. It is a corticosteroid given to speed up the development of the baby’s lungs if preterm birth is likely.

Is used to stop preterm labor contractions: Betamethasone is not used to stop preterm labor contractions. It is given to help mature the baby’s lungs, not to stop labor.

Remind the client to bear down with each contraction: This is not recommended during the active phase of the first stage of labor. The client should be instructed to bear down only during the second stage of labor when the cervix is fully dilated.

Maintain the client in the lithotomy position: This is not necessary during the active phase of the first stage of labor. The lithotomy position is typically used during the second stage of labor for the actual delivery of the baby. During the first stage, the client should be encouraged to find a comfortable position.

Perform vaginal examinations frequently: This is not recommended. Frequent vaginal examinations increase the risk of introducing infection. Vaginal examinations should be performed only when necessary to assess the progress of labor.

Tachycardia: This is not a typical finding in preeclampsia. While some women with severe preeclampsia may experience tachycardia, it is not a defining characteristic of the condition.

Polyuria: This is not typically associated with preeclampsia. In fact, decreased urine output (oliguria) may occur in severe cases due to the effect of preeclampsia on the kidneys.

Absence of clonus: This is not an expected finding. The presence of clonus, not its absence, might be an indication of severe preeclampsia. Clonus is a series of involuntary muscular contractions due to sudden stretching. It can be seen in severe cases of preeclampsia, indicating potential neurological involvement. However, its absence does not rule out preeclampsia.

This option is incorrect because it does not accurately represent the client's pregnancy history. The GTPAL system includes:

• G: Total number of pregnancies
• T: Number of term deliveries (after 37 weeks)
• P: Number of preterm deliveries (between 20 and 37 weeks)
• A: Number of pregnancies ending in spontaneous or elective abortion (before 20 weeks)
• L: Number of living children

For this client:

• G: 4 (one current pregnancy, one abortion, and twins plus one more spontaneous abortion)
• T: 0 (no deliveries at term)
• P: 2 (twins born at 36 weeks and another preterm delivery)
• A: 1 (one spontaneous abortion at 15 weeks)
• L: 2 (living children from the twins)

This option is incorrect because it does not account for the total number of pregnancies or the number of pregnancies ending in abortion accurately.

This option is incorrect because it misrepresents the number of term and preterm deliveries and does not account for the spontaneous abortion correctly.

Accelerations: These are usually a good sign and indicate that the fetus is well-oxygenated.

Late decelerations: These are a sign of uteroplacental insufficiency, not a problem with the umbilical cord. They occur when the blood supply to the placenta is reduced during contractions, leading to a decrease in oxygen supply to the fetus.

Early decelerations: These are usually benign and are often associated with fetal head compression during contractions, not a problem with the umbilical cord.

Assist the client to an upright position: This is not the first action to take. While an upright position can sometimes help with progression of labor, it might not help with the client’s low blood pressure.

Prepare for an immediate vaginal delivery: This is not indicated based solely on the information given. The client’s cervical dilation, effacement, and blood pressure do not indicate that immediate delivery is necessary.

Prepare for a cesarean birth: This is not indicated based solely on the information given. The client’s cervical dilation, effacement, and blood pressure do not indicate that a cesarean birth is necessary.

In about 10 days: This is not correct. Typically, the transition from colostrum to mature milk begins around 3 to 5 days after birth.

Within 2 days: This is not correct. While some women may notice changes in their breasts and the presence of colostrum within 2 days after birth, the transition to mature milk typically takes a bit longer.

In 6 to 8 days: This is not correct. While the exact timing can vary, most women will start to produce mature milk around 3 to 5 days after birth.