A client who is 8 weeks pregnant presents with breast tenderness, morning sickness, and a missed period. Based on the client's symptoms, which of the following, which of the following signs would be classified as presumptive?

A. Vaginal discharge should be assessed to monitor the amount, color, and odor of the amniotic fluid, which can provide information about membrane rupture and possible infection. However, this assessment is secondary to fetal well-being. While it is important to note whether the fluid is clear, meconium-stained, or foul-smelling, it does not provide immediate information about fetal compromise, making it less urgent than FHR assessment.

B. Bladder distention can interfere with labor progression by preventing fetal descent and may require catheterization. Although important during labor management, bladder assessment is not time-critical immediately after amniotomy, and addressing it does not take priority over detecting potential fetal compromise.

C. Maternal blood pressure is routinely monitored to assess maternal cardiovascular status and detect hypertensive disorders such as preeclampsia. While maternal stability is important, unless the mother has known hypertension or symptoms of hypotension, it is not the most urgent assessment immediately after membrane rupture.

D. Fetal heart rate pattern is the priority assessment immediately after amniotomy. Artificial rupture of membranes can increase the risk of umbilical cord prolapse, cord compression, or sudden changes in amniotic fluid volume, all of which can compromise fetal oxygenation. Continuous FHR monitoring allows the nurse to detect variable decelerations, bradycardia, or other signs of fetal distress immediately, enabling prompt interventions such as maternal repositioning, oxygen administration, or notifying the healthcare provider. Monitoring FHR first ensures immediate fetal safety, which is the most critical concern following an amniotomy.

A. Vaginal examination findings are documented in the order of cervical dilation / cervical effacement / fetal station. In this case, 6/90%/−1 means the cervix is 6 cm dilated, 90% effaced, and the fetal presenting part is at −1 station. Fetal station describes the relationship of the presenting part to the ischial spines, which are designated as station 0. Negative numbers indicate the presenting part is above the ischial spines, and positive numbers indicate it is below. Therefore, a station of −1 means the presenting part is 1 cm above the ischial spines, making this interpretation correct.
B. The first number in the documentation represents cervical dilation. A dilation of 6 cm indicates active labor. A dilation of 1 cm would be documented as 1/—/—, not 6, so this interpretation is incorrect.
C. A presenting part that is 1 cm below the ischial spines would be documented as +1 station. Because the finding is −1 station, this option incorrectly interprets the fetal position.
D. The second number represents cervical effacement. An effacement of 90% means the cervix is almost completely thinned and ready for delivery. An effacement of 70% does not match the documented finding and is therefore inaccurate.