📘 The nurse should provide nonjudgmental, realistic, and developmentally appropriate contraceptive counseling to the adolescent.

📘 Discussing contraception supports the client's reproductive autonomy and helps prevent another unintended pregnancy.

📘 The statement encourages the adolescent to actively participate in decisions regarding her sexual and reproductive health.

📘 Adolescents may intend to abstain but later resume sexual activity, making advance discussion of contraceptive options important.

📘 Contraceptive counseling can include highly effective methods such as long-acting reversible contraception, along with other appropriate options.

📘 Counseling should also address condom use for STI prevention, because most other contraceptive methods do not protect against sexually transmitted infections.

📘 The nurse should avoid assumptions, criticism, or moral judgments regarding the teenager's previous or future sexual behavior.

📘 Therefore, discussing contraception before sexual activity resumes is the most therapeutic and preventive response.

📗 The client is demonstrating findings consistent with false labor or the latent/prelabor period, rather than established active labor.

📗 Her contractions are mild, relatively short, and irregularly spaced, occurring every 5 to 9 minutes and lasting only 20 to 30 seconds.

📗 The cervix remains 1 cm dilated and uneffaced after 2 hours, demonstrating no progressive cervical change.

📗 True labor is characterized by regular contractions that progressively increase in frequency, duration, and intensity and produce cervical change.

📗 The Category I fetal heart rate indicates reassuring fetal status and does not suggest a need for immediate delivery.

📗 The client's membranes are intact, and there are no findings indicating an obstetric complication requiring hospitalization.

📗 A stable term client who is not in established labor can generally return home with instructions regarding when to return to the hospital.

📗 Therefore, discharge home to await the onset of true labor is the expected next step.

✅ Upon admission to the hospital at the start of labour

🌸 A vaginal examination is commonly performed during the initial labor assessment when clinically appropriate.

🌸 The examination determines cervical dilatation and effacement, which help establish the client's labor status.

🌸 It can also identify the fetal presenting part, position, and station when these can be palpated.

🌸 Baseline cervical findings allow subsequent examinations to determine whether labor is progressing.

🌸 The examination also helps distinguish true labor from false labor by documenting cervical changes over time.

🌸 Vaginal examinations should be limited to those that are clinically necessary because repeated examinations can increase infection risk.

🌸 Special circumstances, such as unexplained vaginal bleeding or placenta previa, can make digital examination inappropriate until the cause is evaluated.

🌸 Therefore, an admission vaginal examination is appropriate when assessing a client presenting in labor.

✅ When the client feels perineal pressure

🌸 Increasing perineal or rectal pressure can indicate rapid fetal descent and progression toward the second stage of labor.

🌸 The sensation may occur as the presenting fetal part descends deeper into the maternal pelvis.

🌸 A vaginal examination can determine whether the cervix has reached complete dilatation.

🌸 The examination can also assess the station and descent of the presenting part.

🌸 This information is important before encouraging the client to begin active pushing.

🌸 Pushing before complete cervical dilatation can contribute to cervical edema or injury.

🌸 A sudden urge to bear down or increased pressure can indicate that birth is becoming imminent.

🌸 Therefore, new perineal pressure is an appropriate indication for a vaginal examination.

✅ With either spontaneous or artificial rupture of membranes

🌸 A vaginal examination may be indicated after rupture of membranes to evaluate the presenting part and assess for complications when clinically appropriate.

🌸 A major concern following membrane rupture is umbilical cord prolapse, particularly when the presenting part is not well engaged.

🌸 Cord prolapse can cause cord compression and acute fetal hypoxia.

🌸 The nurse should immediately assess the fetal heart rate following rupture of membranes because fetal bradycardia or variable decelerations can indicate cord compression.

🌸 Vaginal examination can help identify a prolapsed cord when fetal heart rate abnormalities or other clinical findings raise concern.

🌸 The examination can also provide information regarding cervical status and the relationship of the presenting part to the pelvis.

🌸 Examinations should still be minimized after membrane rupture because repeated vaginal examinations increase the risk of ascending infection.

🌸 Therefore, rupture of membranes is a circumstance in which vaginal assessment may be indicated.

✅ Encouraging clients to keep all prenatal appointments and if one needs to be missed to call and reschedule

🌼 Regular prenatal care allows healthcare providers to identify maternal or fetal conditions that can increase the risk of preterm labor and birth.

🌼 Prenatal appointments provide opportunities to assess maternal blood pressure, weight, fetal growth, and overall pregnancy progression.

🌼 Providers can identify risk factors such as infection, cervical changes, hypertension, or other pregnancy complications before they become severe.

🌼 Keeping scheduled appointments also provides opportunities for ongoing education about warning signs of preterm labor.

🌼 Clients who cannot attend an appointment should reschedule promptly rather than simply missing prenatal care.

🌼 Consistent prenatal monitoring supports early intervention when abnormalities are identified.

🌼 Early recognition and management of pregnancy complications can reduce the likelihood of adverse maternal and fetal outcomes.

🌼 Therefore, maintaining regular prenatal appointments is an important component of preterm birth prevention education.

✅ Reporting symptoms of urinary frequency and burning to the health-care provider

🌼 Urinary frequency accompanied by burning can indicate a urinary tract infection rather than normal pregnancy-related urinary frequency alone.

🌼 Maternal urinary tract infections are associated with an increased risk of preterm labor when they are not appropriately treated.

🌼 Pregnancy can increase susceptibility to urinary infections because of physiologic changes in the urinary tract.

🌼 Clients should promptly report symptoms such as dysuria, urgency, frequency, fever, or flank pain.

🌼 Early evaluation allows appropriate testing and treatment before the infection progresses.

🌼 Untreated infection can stimulate inflammatory responses that may contribute to uterine contractions and preterm birth.

🌼 Teaching clients to recognize infection symptoms promotes early intervention and reduces preventable complications.

🌼 Therefore, urinary frequency accompanied by burning should be reported promptly.

✅ Coming to the labour triage unit if back pain or cramping persist or become regular

🌼 Persistent low back pain and abdominal or menstrual-like cramping can be manifestations of preterm labor.

🌼 Preterm contractions may initially be mild and may not be recognized by the client as true uterine contractions.

🌼 Regular or progressively persistent cramping warrants prompt maternal and fetal evaluation.

🌼 Early assessment can determine whether contractions are producing cervical dilatation or effacement.

🌼 Other warning signs can include pelvic pressure, changes in vaginal discharge, vaginal spotting, or leaking fluid.

🌼 Prompt evaluation is particularly important when these symptoms occur before 37 completed weeks of gestation.

🌼 Early recognition provides an opportunity for appropriate interventions when indicated to improve maternal and neonatal outcomes.

🌼 Therefore, persistent or regular back pain and cramping should prompt evaluation in labor triage.

✅ Increased vaginal bleeding

🏵️ During the third stage of labor, the placenta separates from the uterine wall after the birth of the newborn.

🏵️ A sudden gush or increase in vaginal bleeding is a classic sign that placental separation has occurred.

🏵️ Separation disrupts maternal blood vessels located at the placental implantation site.

🏵️ Blood can collect behind the separating placenta before becoming visible vaginally.

🏵️ As the placenta separates more completely, this accumulated blood may suddenly be expelled through the vagina.

🏵️ Other signs of placental separation should be assessed together rather than relying on bleeding alone.

🏵️ The uterus also typically becomes firm, globular, and rises in the abdomen as separation occurs.

🏵️ Therefore, increased vaginal bleeding is an expected sign of placental separation.

✅ Cord lengthens

🏵️ Lengthening of the umbilical cord at the vaginal opening is another classic sign of placental separation.

🏵️ Once separated, the placenta descends from the uterine wall into the lower uterine segment and vagina.

🏵️ As the placenta moves downward, more of the attached umbilical cord becomes visible externally.

🏵️ The nurse therefore observes an apparent increase in the length of the cord outside the vagina.

🏵️ Cord lengthening commonly occurs along with a gush of blood and changes in uterine shape.

🏵️ These findings indicate progression through the third stage of labor.

🏵️ The cord should not be pulled forcefully because inappropriate traction can contribute to serious complications.

🏵️ Therefore, cord lengthening is a characteristic sign that the placenta has separated.

🌹 Crowning occurs when the fetal head remains visible at the vaginal opening and indicates that birth is imminent.

🌹 The nurse should remain with the client and immediately prepare to assist with the birth rather than leaving her unattended.

🌹 The nurse should simultaneously call for additional assistance because another healthcare professional may be needed to support the mother and newborn.

🌹 Completing routine procedures such as the perineal preparation becomes secondary once imminent birth is recognized.

🌹 The nurse should support the fetal head as it emerges while allowing birth to occur in a controlled manner.

🌹 Appropriate support helps minimize rapid expulsion of the fetal head and reduces unnecessary maternal tissue trauma.

🌹 The nurse should be prepared to provide immediate newborn assessment, warming, airway support if needed, and maternal care following birth.

🌹 Therefore, preparing to assist with the birth while calling for assistance is the safest response when crowning occurs.

🖊️ Chronic diabetes can be an indication for induction because prolonged pregnancy can increase maternal and fetal complications, including macrosomia and placental dysfunction.

🖊️ The timing of delivery in a client with diabetes depends on glycemic control, fetal status, and maternal complications.

🖊️ A post-term pregnancy is an established indication for induction because risks increase as pregnancy continues beyond the recommended gestational period.

🖊️ Post-term pregnancy increases the risk of placental insufficiency, oligohydramnios, macrosomia, and meconium aspiration.

🖊️ A history of rapid or precipitous labor can be considered for planned induction when appropriate because of the risk of an unplanned birth before reaching the healthcare facility.

🖊️ Induction should only occur when the benefits of delivery outweigh the risks of continuing the pregnancy.

🖊️ Before induction, the healthcare team evaluates fetal presentation, cervical readiness, fetal status, and contraindications to vaginal birth.

🖊️ Therefore, chronic diabetes, post-term pregnancy, and a history of rapid labor represent the appropriate group of indications among these choices.

Formula:

mL/hr = Dose prescribed ÷ Dose available × Volume available

➤ Dose prescribed = 2 g/hr

➤ Dose available = 20 g

➤ Volume available = 1000 mL

2 g ÷ 20 g × 1000 mL = 100 mL/hr