A primigravida arrives at the maternity unit’s observation area because she believes she is in labor.
The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes.
Which assessment finding would confirm to the nurse that the client is not in labor at this time?

Choice A rationale

Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.

Choice B rationale

An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.

Choice C rationale

Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.

Choice D rationale

Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.

Choice A rationale

While the estimated amount of fluid can provide some information about the volume of amniotic fluid lost, it is not the most critical piece of information. The amount of fluid can vary and does not necessarily indicate the progression of labor.

Choice B rationale

Any odor noted when the membranes ruptured can be a sign of infection. However, this is not the most crucial information to obtain immediately as it does not directly impact the management of labor.

Choice C rationale

The time the membranes ruptured is the most important information to obtain. This is because the risk of infection increases the longer the time between membrane rupture and delivery.

Knowing the time of rupture helps guide decisions about inducing labor and administering antibiotics to prevent infection.

Choice D rationale

The color and consistency of the fluid can provide information about the presence of meconium or blood, which could indicate fetal distress or placental problems. However, this is not the most critical information to obtain immediately.