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

The eye ointment used in newborns is not intended to clear the infant’s vision.

Choice B rationale

The purpose of the eye ointment is not to dilate the pupil for visualization of the red reflex.

Choice C rationale

While the ointment does help prevent infections, it is not specifically targeted against herpes.

Choice D rationale

The primary purpose of the eye ointment is to prevent eye infections in newborns. This is particularly important as mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)1.

Choice A rationale

Bright red bleeding in the third trimester of a pregnancy with an Rh-negative mother is an obstetric emergency and warrants the highest priority. The immediate assessment of the fetal heart rate (FHR) and the mother's contraction pattern is crucial. The nurse must determine if the bleeding is caused by conditions such as placental abruption or placenta previa, both of which are life-threatening for the mother and the fetus.

Choice B rationale

While a sterile vaginal examination may eventually be necessary to diagnose the cause of bleeding, it is not the immediate priority. Assessment of fetal well-being and maternal status takes precedence. Additionally, performing a vaginal examination increases the risk of further hemorrhage and potential infection.

Choice C rationale

Leopold maneuvers are used to determine fetal presentation and position, but they are not the priority intervention in this scenario. The nurse's main concern is stabilizing the mother and assessing for signs of fetal distress.

Choice D rationale

Assessing the woman's Rh and Coombs status for RhoGam administration is important. Still, it is not the most immediate priority in this life-threatening situation. The priority is to assess fetal well-being and stabilize the mother. If placental abruption is suspected, RhoGam administration may not be indicated.