A nurse is assisting in the care of a client who is in labor.
The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

Choice A rationale

Ensuring the car seat is securely installed and properly buckled is paramount for infant safety. Correct installation prevents excessive movement of the car seat during a collision, and proper buckling ensures the infant is restrained effectively, reducing the risk of ejection or injury from impact forces.

Choice B rationale

Using an expired car seat or one that has been involved in a previous accident is highly dangerous. Over time, materials degrade, and the structural integrity of a car seat can be compromised after an accident, even if there are no visible signs of damage. Expired seats may not meet current safety standards.

Choice C rationale

Always placing the car seat in the front seat, facing forward, is incorrect and extremely dangerous. The front passenger airbag can deploy with significant force, causing severe or fatal injuries to an infant in a car seat. Infants and young children should always be in the back seat to mitigate this risk.

Choice D rationale

Placing the car seat in the middle of the back seat, facing forward, is incorrect for infants. Infants should always be in a rear-facing car seat until they meet the maximum height or weight limits for their rear-facing car seat, typically around 2 years of age or older. The middle back seat is generally safest for placement due to optimal crash protection.

Choice A rationale

Notifying the healthcare provider immediately and requesting antibiotics is premature. Slight redness around pin sites without drainage or pain, and stable vital signs, does not immediately indicate a significant infection requiring systemic antibiotics. This initial finding warrants a thorough assessment and local care before escalating to medical intervention.

Choice B rationale

Removing crusting around pin sites can be detrimental. Crusting can serve as a protective barrier. Aggressive removal can introduce bacteria into the pin tract, increasing the risk of infection, or cause unnecessary pain and trauma to the delicate healing tissue. Gentle cleansing is preferred over forceful removal of adherent crusts.

Choice C rationale

Cleansing the pin sites using sterile saline and assessing for signs of infection is the best immediate action. Slight redness without drainage is often a normal inflammatory response to the foreign body and movement. Sterile saline effectively cleanses without irritating the tissue, and continued assessment helps monitor for evolving signs like increased redness, purulent drainage, or fever.

Choice D rationale

Documenting findings as normal and continuing routine assessments is insufficient. While slight redness can be normal, it still requires diligent monitoring and appropriate pin site care to prevent potential complications. Assuming normalcy without active intervention like cleansing could allow a minor irritation to progress to a more serious infection. .