A nurse is caring for a client in the emergency department who is in active labor on December 26. The client reports their last menstrual period was around April 1. Which of the following ages is the anticipated gestational age of the fetus?

Choice A rationale

While monitoring vital signs (temperature, heart rate, and blood pressure) is important for overall maternal assessment, in the context of strong contractions and reported nausea/urge to defecate, these specific vital signs are not the immediate priority for identifying the most critical complication. Normal temperature is 36.5-37.5°C, heart rate 60-100 bpm, blood pressure 90/60 to 120/80 mmHg.

Choice B rationale

The client's symptoms (strong contraction, nausea, urge to defecate) strongly suggest the second stage of labor, specifically an urge to push. The highest priority is to determine the fetal heart rate in relationship to the contraction, as this immediate assessment evaluates fetal well-being and detects potential distress, like late decelerations, indicating uteroplacental insufficiency.

Choice C rationale

Examining vaginal discharge for meconium is important if there are signs of fetal distress, but assessing the fetal heart rate pattern in relation to contractions directly provides real-time information about fetal oxygenation and is therefore the immediate priority when assessing labor progress with these symptoms.

Choice D rationale

Performing a vaginal examination to assess labor progress is a crucial step to confirm cervical dilation and fetal descent. However, before internal examination, ensuring fetal well-being through external monitoring of the fetal heart rate during contractions is paramount, especially with the client's reported symptoms suggesting advanced labor.

Choice A rationale

While thermoregulation is critical for newborns, directly placing a newborn with an omphalocele under a radiant heat source without covering the exposed viscera first can lead to excessive fluid loss and potential hypothermia due to evaporation. The primary concern is protecting the exposed abdominal contents from injury and infection.

Choice B rationale

Positioning a newborn with an omphalocele in a supine position is generally appropriate, as it helps to keep the exposed viscera in a less compromised position. However, the most immediate and critical action is to protect the exposed organs from trauma, desiccation, and infection before considering positioning.

Choice C rationale

Using sterile plastic wrap to cover the viscera of a newborn with an omphalocele is a critical immediate nursing action. This creates a sterile barrier, prevents desiccation of the exposed abdominal contents, minimizes heat and fluid loss, and reduces the risk of infection, thus protecting the delicate organs until surgical repair.

Choice D rationale

Applying petroleum gauze to the exposed viscera is not the most appropriate or effective method for protecting an omphalocele. Petroleum gauze may stick to the delicate tissues, potentially causing trauma upon removal, and does not provide the same level of sterile barrier, moisture retention, or protection against environmental contaminants as sterile plastic wrap.