A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip.
Which data is most important for the nurse to monitor?

Choice A rationale

Administering oxygen would not be the priority as the fetal heart rate is normal and there are no abnormal fetal movements or signs of distress. Oxygen administration is typically reserved for cases where there is evidence of fetal hypoxia or distress.

Choice B rationale

Checking cervical dilation is essential as it provides critical information about the progress of labor and helps in determining the next steps in management. It ensures that the labor is progressing appropriately and identifies if there is a need for any medical interventions.

Choice C rationale

Starting an intravenous fluid bolus would not be the first action in this scenario as the client does not show signs of dehydration or hypotension. Fluid bolus is generally reserved for cases where there is evidence of hypovolemia or to support hemodynamic stability.

Choice D rationale

Preparing for immediate delivery is not necessary at this stage as there are no signs of fetal distress or urgent complications. The client is only 37 weeks gestation and regular assessment is crucial to ensure timely and appropriate interventions without premature actions.

Choice A rationale

While vitamin K is indeed administered to newborns to help with blood clotting, it is given intramuscularly (IM) and not subcutaneously (SUBQ). Subcutaneous injections are not typically used for administering vitamin K to newborns due to absorption issues.

Choice B rationale

Vitamin K is given to newborns to prevent bleeding disorders, as they are born with low levels of this essential vitamin. This is a standard practice to prevent Vitamin K Deficiency Bleeding (VKDB) in newborns.

Choice C rationale

Blood drawing is a common procedure in newborns, but it usually involves a heel stick, not a needle mark in the thigh. Hemoglobin and hematocrit levels are generally checked to assess the baby's blood count, not for vitamin K administration.

Choice D rationale

While the thigh is a common site for injections in infants, this response does not address the mother's concern about the specific reason for the needle mark. It is important to provide a clear and direct explanation.