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:

Amniotic fluid in the vaginal vault may indicate that the client's membranes have ruptured, but it does not necessarily mean

that labor has begun. Some women experience rupture of membranes before labor starts, while others do not experience it

until labor is well underway.

Additionally, it is not always possible to visually confirm the presence of amniotic fluid, as it may be mixed with other fluids or

present in small amounts.

Therefore, the presence of amniotic fluid alone is not a definitive sign of labor.

Choice B rationale:

Contractions are a common sign of labor, but they can also occur for other reasons, such as Braxton Hicks contractions or a

urinary tract infection.

To be considered a sign of true labor, contractions should be regular, becoming progressively stronger, longer, and closer

together.

A frequency of every 3 to 4 minutes is often suggestive of labor, but it is not always definitive.

Some women may experience contractions that are less frequent or more irregular and still be in labor.

Choice C rationale:

Cervical dilation is the most reliable sign of labor.

During labor, the cervix gradually opens to allow the baby to pass through the birth canal.

Cervical dilation is typically measured in centimeters, with 10 centimeters being considered full dilation.

Once the cervix has dilated to 3-4 centimeters, it is generally considered to be active labor.

This is because dilation of this degree usually indicates that the contractions are strong enough to effectively move the baby

through the birth canal.

Choice D rationale:

Pain just above the navel, also known as suprapubic pain, can be a sign of labor, but it is not a definitive one.

This type of pain can also be caused by other factors, such as bladder fullness or indigestion.

Additionally, not all women experience pain in this area during labor.

Rationale for Choice A:

Nipple shields are typically recommended for breastfeeding mothers experiencing nipple pain or thrush. While the client may

be experiencing some breast engorgement due to the hard and warm feeling, there is no indication of nipple pain or thrush.

Therefore, using a nipple shield is not the most appropriate recommendation in this case.

Rationale for Choice B:

Obtaining a prescription for an antibiotic is not warranted at this time. While mastitis, a breast infection, can occur

postpartum, the client's symptoms of moderate lochia rubra and firm, warm breasts are not specific enough to indicate

mastitis. Additionally, unnecessary antibiotic use should be avoided as it can contribute to antibiotic resistance.

Rationale for Choice C:

Applying a heating pad to the breasts may initially provide some comfort, but it can worsen engorgement and inflammation.

Heat stimulates milk production, which can further contribute to the client's discomfort. Applying cold compresses or ice

packs would be a more appropriate intervention for reducing inflammation and breast engorgement.

Rationale for Choice D:

Expressing milk from both breasts is the most appropriate recommendation for the client experiencing breast engorgement.

Regular milk removal helps to reduce milk build-up, alleviate engorgement, and decrease the risk of mastitis. The nurse can

teach the client proper handwashing techniques and breast massage strategies to facilitate effective milk expression.

Additionally, the nurse can encourage the client to breastfeed frequently, as this is the most efficient way to remove milk and

prevent engorgement.

Additional Notes:

The client's postpartum day (3 days) is a significant factor in considering the cause of her symptoms. Breast engorgement is

common during the first few days postpartum as milk production becomes established.

The nurse should assess the client's breastfeeding technique and ensure proper latching to prevent nipple trauma and

encourage effective milk removal.

Monitoring the client's temperature and other vital signs is crucial for identifying potential signs of infection, such as mastitis.

Providing the client with supportive measures such as comfortable bras and pain relief medications can also contribute to her

comfort and well-being.

By addressing the underlying cause of breast engorgement (milk build-up) through milk expression, the nurse can effectively

manage the client's symptoms and prevent potential complications like mastitis.