A client arrives in labor and delivery having contractions every 8-10 minutes, lasting 30 seconds, and palpated as hard.Fetal heart rate is 124-138 with good variability.
Maternal vital signs are 98.4°F temp, HR 88, RR 20, BP 112/64. Membranes are intact and vaginal exam reveals: cervix is 80% effaced, 3 cm dilated, head -2 station.
The nurse knows that the patient is in which stage of labor?

Choice A rationale: Initiating continuous electronic fetal monitoring is essential to assess the fetal heart rate and detect any signs of fetal distress. Given the history of decreased fetal movements, it's crucial to monitor the baby's condition closely.

Choice B rationale: Administering magnesium sulfate is recommended for neuroprotection in preterm deliveries, particularly for pregnancies less than 32-34 weeks gestation. It helps reduce the risk of cerebral palsy in preterm infants.

Choice C rationale: Performing a sterile speculum exam is unnecessary since the rupture of membranes has already been confirmed through the presence of amniotic fluid pooling and positive ferning test results.

Choice D rationale: Preparing the client for an emergency C-section is not immediately necessary unless there are signs of fetal distress or other complications. The priority is to stabilize the client's condition and monitor both the mother and the baby.

Choice E rationale: Monitoring for signs of chorioamnionitis is crucial since the client presents with ruptured membranes. Chorioamnionitis is a potential infection that can occur with prolonged rupture of membranes, which can lead to maternal and fetal complications. Monitoring includes assessing for fever, uterine tenderness, and foul-smelling amniotic fluid.

Choice A rationale

Administering epinephrine before the procedure is not standard practice to prevent hypotension associated with epidurals. Epinephrine is used in emergency situations to treat severe allergic reactions or cardiac arrest, not for preventing epidural-induced hypotension.

Choice B rationale

Positioning the client on her back prior to the procedure is not recommended, as it can exacerbate hypotension due to compression of the inferior vena cava by the gravid uterus. This position can decrease venous return to the heart and reduce cardiac output.

Choice C rationale

Having the patient eat a carbohydrate snack prior to the procedure is not a standard intervention to prevent hypotension during an epidural. Dietary intake does not directly prevent the vasodilatory effects of the epidural anesthesia.

Choice D rationale

Administering a bolus of 0.9% Normal saline IV fluid before the procedure is the correct intervention to prevent hypotension. Preloading with IV fluids increases intravascular volume, counteracting the vasodilation and potential drop in blood pressure caused by the epidural anesthesia. .