A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control.
Findings of the last vaginal exam, performed one hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station.
Which action should the nurse implement first?

Step 1 is (2 grams/hour ÷ 20 grams) × 500 mL.

Step 2 is (2 ÷ 20) × 500.

Step 3 is 0.1 × 500. The final calculated answer is 50 mL/hour.

Choice A rationale

Flexion of all four extremities is a normal finding in newborns but does not specifically indicate successful transition to extrauterine life. It suggests good muscle tone, which is important, but vigorous crying is a more direct sign of effective respiratory effort and lung function.

Choice B rationale

A positive Babinski reflex is a normal reflexive response in newborns, indicating proper neurological function. However, it does not provide direct information about the newborn's respiratory or cardiovascular adaptation to life outside the womb.

Choice C rationale

Crying vigorously when stimulated is a strong indicator that the newborn is transitioning well to extrauterine life. It demonstrates that the infant's lungs are functioning properly, and they are capable of clearing airway secretions and maintaining adequate oxygenation, which are critical for survival outside the uterus.

Choice D rationale

A heart rate of 220 beats/minute is significantly higher than the normal range for newborns (120-160 beats/minute). Such tachycardia could indicate stress, dehydration, or underlying cardiac issues and does not reflect a normal transition to extrauterine life. .