A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

Correct Answer: B

Rationale: The correct answer is B: A surge of energy. This is because an increase in energy is often seen in pregnant women shortly before labor begins, known as the "nesting instinct." This burst of energy can indicate that the body is preparing for labor. A: Decreased vaginal discharge is not a sign that precedes labor. In fact, an increase in vaginal discharge is more common as labor approaches. C: Urinary retention is not a sign of labor onset. In late pregnancy, pressure on the bladder may cause frequent urination, but retention is not typical. D: Weight gain of 0.5 to 1.5 kg is not a specific sign of labor onset. Weight gain can fluctuate throughout pregnancy and is not a reliable indicator of impending labor.

Correct Answer: D

Rationale: The correct answer is D because a breathing pattern that is diaphragmatic with sternal retractions indicates respiratory distress in a newborn, which is a critical condition requiring immediate attention. Staying logical, let's assess the other choices: A: Temperature of 97.7 degrees Fahrenheit is within the normal range for a newborn and does not indicate an urgent issue. B: A pale pink, rust-colored stain in the diaper could be due to various factors such as diet and is not an immediate concern. C: A heart rate dropping to 120 beats/min in a newborn is generally within the normal range and does not signify a critical issue.

Correct Answer: A

Rationale: The correct answer is A: Place the newborn in skin-to-skin contact with the mother. This is the best nursing action for a newborn experiencing hypothermia because it provides immediate and effective warmth transfer from the mother to the baby. Skin-to-skin contact helps regulate the newborn's body temperature, promotes bonding, and enhances breastfeeding initiation. Choice B is incorrect because while providing a warm blanket is important, skin-to-skin contact with the mother is more effective in quickly raising the newborn's temperature. Choice C is incorrect because administering IV fluids is not the first-line treatment for hypothermia in newborns. Choice D is incorrect because monitoring glucose levels for hypoglycemia is important but addressing the hypothermia should take precedence.

Correct Answer: B

Rationale: The correct answer is B: Provide IV antibiotics. Fever during labor could indicate infection, which can be harmful to both the mother and baby. Administering IV antibiotics is the priority action to treat the infection promptly and prevent complications. Administering antipyretics only treats the symptom, not the underlying cause. Encouraging hydration orally may be important but should not take precedence over addressing a potential infection. Notifying the healthcare provider is important, but immediate intervention with antibiotics is crucial in this situation.

Correct Answer: C

Rationale: The correct answer is C: Encourage the mother to avoid heavy lifting. After a third-degree perineal tear, it is crucial to prevent strain on the perineum to promote healing and prevent complications like infection or further tearing. Heavy lifting can increase pressure on the perineum, leading to delayed healing. Ice packs (A) may help reduce swelling initially but do not address the underlying issue. Stool softeners (B) can help prevent constipation and straining during bowel movements but do not directly impact perineal tear healing. Perineal exercises (D) are beneficial for strengthening the pelvic floor muscles in general but should be introduced gradually and not immediately postpartum with a severe tear.