The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

Choice A rationale Performing a vaginal exam is crucial in assessing the progress of labor and the condition of the cervix, particularly if the client has reported symptoms such as contractions, bleeding, or fluid leakage. It helps determine if the client is in active labor or if there are any complications requiring immediate intervention. Choice B rationale Taking vital signs is essential to assess the client's overall health and identify any signs of distress or complications. Vital signs provide critical information about the client's cardiovascular and respiratory status, which is important for immediate clinical decision-making. Choice C rationale Palpating the bladder is important in assessing for bladder distention, which can impede labor progress or cause discomfort. However, it is not the immediate priority compared to assessing labor progress and overall health status. Choice D rationale Examining the amniotic fluid is important for determining its characteristics, which can provide information about the fetal well-being. However, this action is secondary to performing a vaginal exam and taking vital signs in the immediate assessment. Choice E rationale Dipstick urine for protein and ketones helps in assessing for preeclampsia or gestational diabetes, but it does not address the immediate need to assess labor progress and the client's overall health status.