The nurse is caring for a client in labor with her third baby. She is 39 weeks gestation, 6 cm dilated, 80% effaced, and 0 station, with minimal variability and recurrent variable decelerations. What action is the highest priority for the nurse?

Correct Answer: B

Rationale: The correct answer is B: Change maternal position. This is the highest priority because the client is experiencing recurrent variable decelerations, which can indicate umbilical cord compression. Changing the maternal position can help relieve the pressure on the cord, potentially improving fetal oxygenation. Administering oxygen (choice A) can be important but addressing the cause of the variable decelerations is crucial. Performing fetal scalp stimulation (choice C) is not appropriate at this time as the focus should be on improving fetal oxygenation. Performing a vaginal examination (choice D) is not necessary at this moment and may even exacerbate the situation.

Correct Answer: C

Rationale: The correct answer is C: 2, 1. Gravida refers to the total number of pregnancies, including the current one. The patient delivered triplets 2 years ago, so she is currently pregnant again, making her total pregnancies 2. Para refers to the number of deliveries after 20 weeks of gestation, regardless of the number of fetuses. Since she delivered triplets 2 years ago, she had 1 delivery after 20 weeks of gestation, making her para 1. Choices A, B, and D are incorrect as they do not accurately reflect the patient's obstetric history based on the information provided.

Correct Answer: A

Rationale: The correct answer is A: Abdominal pain. This complaint at 35 weeks of gestation requires additional assessment as it could indicate a serious issue such as preterm labor, placental abruption, or other complications. Abdominal pain in late pregnancy should never be ignored. Ankle edema in the afternoon, backache with prolonged standing, and shortness of breath when climbing stairs are common discomforts in pregnancy and may not necessarily indicate a serious problem at this stage.

Correct Answer: A

Rationale: The correct answer is A: Rubella titer, 1:6. A low rubella titer indicates susceptibility to rubella infection, which can be harmful during pregnancy. Rubella can lead to birth defects or miscarriage. Platelets, WBC count, and hematocrit/hemoglobin levels are within normal range and not typically concerning during the early stages of pregnancy.

Correct Answer: A

Rationale: The correct answer is A: Chew gum or suck on lozenges between meals. Ptyalism is excessive saliva production during pregnancy. Chewing gum or sucking on lozenges can help manage excessive saliva by promoting swallowing and reducing the sensation of saliva accumulation. This guidance addresses the symptom directly. Choices B, C, and D do not specifically address ptyalism. B focuses on nutrition, C on circulation, and D on physical comfort, which are important aspects of pregnancy but not directly related to managing ptyalism.