The nurse is caring for a client in labor with meconium-stained amniotic fluid. What is the priority action?

Correct Answer: C

Rationale: Meconium-stained amniotic fluid poses a risk of aspiration; preparation for neonatal resuscitation is critical.

Correct Answer: B

Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."

Correct Answer: C

Rationale: The gate control theory of pain proposes that non-painful input can close the "gates" to painful input, which helps to control and reduce pain perception. Massage, such as massaging the client's back, is a non-pharmacological intervention that can help close the gates and reduce the perception of pain. By massaging the client's back, the nurse is applying this theory to help manage the client's labor pain. Administering analgesic medication (Choice A) is a pharmacological intervention and not specifically related to the gate control theory. Choices B and D are also beneficial nursing actions but do not directly relate to the gate control theory of pain.

Correct Answer: B

Rationale: Prolonged contractions lasting more than 90-120 seconds may reduce placental perfusion and oxygenation to the fetus, leading to fetal distress. This can result in fetal hypoxia and compromise. Therefore, if the contraction duration reaches 100 seconds, it is an indication for the nurse to discontinue the oxytocin infusion to prevent harm to the fetus. Monitoring for appropriate contraction duration is crucial to ensure the well-being of both the mother and the fetus during labor. While contraction frequency every 3 minutes, a fetal heart rate with moderate variability, and a fetal heart rate of 118/min can be normal findings during labor, a prolonged contraction duration is a concerning sign that requires immediate intervention.

Correct Answer: D

Rationale: Incompetent cervix, also known as cervical insufficiency, is a condition where the cervix begins to dilate and efface prematurely due to weak cervical tissue. This can lead to late miscarriage or preterm birth. Adolescent mothers are at a higher risk for this complication due to their immature reproductive systems. Therefore, the nurse should plan to monitor for signs and symptoms of incompetent cervix in adolescent pregnant clients to prevent adverse maternal and fetal outcomes. Anemia, placenta previa, and abruptio placenta are other potential complications of pregnancy, but they are not specifically associated with adolescent pregnancy.