A nurse is assisting in the care of a client who is in the second stage of labor.
Which of the following findings should the nurse report to the provider?

Choice A rationale:

Urinary retention is not a common sign of impending labor. In fact, it's more likely to occur in the early stages of pregnancy

due to hormonal changes and the pressure of the growing uterus on the bladder. As labor approaches, the baby's head often

descends into the pelvis, which can relieve some of the pressure on the bladder and make urination more frequent, not less

frequent.

Urinary retention can be a sign of other medical concerns, such as a urinary tract infection or problems with bladder function.

It's important to report any difficulty urinating to a healthcare provider for proper evaluation and treatment.

Choice B rationale:

A decrease in vaginal discharge is not typically associated with impending labor. On the contrary, many women notice an

increase in vaginal discharge, often referred to as "bloody show," as labor approaches. This discharge is typically pink or

brownish in color and may contain streaks of blood. It's caused by the release of the mucus plug that seals the cervix during

pregnancy.

A decrease in vaginal discharge could be a sign of other issues, such as a decrease in amniotic fluid or a yeast infection. It's

important to report any changes in vaginal discharge to a healthcare provider for assessment.

Choice D rationale:

A weight gain of 0.5 to 1.5 kilograms (1 to 3 pounds) is not a reliable sign of impending labor. Weight fluctuations are common

in late pregnancy due to factors such as fluid retention and changes in blood volume. Some women may even lose a small

amount of weight in the days leading up to labor.

While significant weight gain (more than 2 kilograms or 4 pounds in a week) could indicate a potential issue like preeclampsia,

a small weight gain or loss is not typically a cause for concern in terms of labor onset.

Choice C rationale:

A surge of energy, often referred to as "nesting instinct," is a common sign that labor may be approaching. This sudden burst of

energy can manifest as a strong urge to clean, organize, and prepare the home for the baby's arrival. It's thought to be caused

by a combination of hormonal changes and the body's natural instincts to prepare for childbirth.

While the exact timing of labor is unpredictable, experiencing a surge of energy, especially in conjunction with other signs like

increased Braxton Hicks contractions, lower back pain, or pelvic pressure, may suggest that labor is likely to start within the

next few days or weeks.

Rationale for Choice A:

Checking the client's fundus is an important assessment in the postpartum period, but it is not the most immediate action

when a large amount of lochia rubra with clots is present. A boggy or displaced fundus could indicate subinvolution or

hemorrhage, but these are not the most likely causes of the presenting symptoms.

Rationale for Choice B:

Performing a vaginal examination is the most appropriate first action in this situation. This will allow the nurse to directly

assess the source and amount of bleeding, as well as to check for any retained placental fragments or cervical lacerations.

These findings could be the cause of the lochia rubra and clots, and prompt intervention may be necessary.

Rationale for Choice C:

While measuring the client's vital signs is an important part of the postpartum assessment, it is not the most immediate action

when there is evidence of active bleeding. Taking vital signs can be delayed while the nurse performs a vaginal examination to

assess the source and severity of the bleeding.

Rationale for Choice D:

Checking for a full bladder is not the most relevant action in this situation. A full bladder can contribute to postpartum

discomfort, but it is not likely to be the cause of the lochia rubra and clots. Addressing the bleeding should be the priority.