A maternal indication for the use of vacuum extraction is

Choice A reason:

Hypothermia is the priority area for this newborn because the axillary temperature of 95.8° F (35.4° C) is below the normal range of 97.7° F to 99.5° F (36.5° C to 37.5° C) for newborns1. Hypothermia can lead to complications such as hypoglycemia, metabolic acidosis, and impaired oxygen delivery2. The nurse should initiate interventions to warm the newborn, such as skin-to-skin contact, radiant warmer, or swaddling2.

Choice B reason:

Deficient fluid volume is not the priority area for this newborn because the apical pulse of 114 beats per minute is within the normal range of 100 to 160 beats per minute for newborns345. A low pulse rate can indicate dehydration or shock in newborns2. The nurse should monitor the newborn's fluid intake and output, weight, and signs of dehydration, such as dry mucous membranes, sunken fontanels, and poor skin turgor2.

Choice C reason:

Impaired gas exchange is not the priority area for this newborn because the respiratory rate of 60 breaths per minute is within the normal range of 30 to 60 breaths per minute for newborns345. A high or low respiratory rate can indicate respiratory distress or failure in newborns2. The nurse should assess the newborn's breath sounds, chest movements, oxygen saturation, and signs of respiratory distress, such as nasal flaring, grunting, retractions, and cyanosis2.

Choice D reason:

Risk for infection is not the priority area for this newborn because there is no evidence of infection in the vital signs or the question stem. However, newborns are vulnerable to infection due to their immature immune systems and exposure to pathogens during birth and aftercare2. The nurse should follow infection control measures, such as hand hygiene, aseptic technique, and cord care, and educate the parents on how to prevent infection at home2.

Choice A reason:

While positioning is important for comfort during labor, addressing the immediate urge to push takes priority. Panting during contractions is the appropriate action.

Choice B reason:

Although observing for crowning is important when the client is close to delivery, the nurse should first intervene to address the client's urge to push since the client is only 7 cm dilated.

Choice C reason:

When a laboring client feels the urge to push but is not yet fully dilated (10 cm), encouraging her to pant can help reduce the urge to push and avoid complications, such as cervical swelling or tearing. This breathing technique helps the client delay pushing until full dilation and readiness of the cervix.
Choice D reason:

Assisting the client to the bathroom would not be appropriate at this stage of labor because the urge to push could lead to unsafe delivery outside the appropriate setting, and movement could increase discomfort or risks.