A nurse has assessed a patient in labor.
The patient’s cervix is dilated 4 cm and 100% effaced.
The fetus is in the vertex presentation at -1 station.
The patient is walking to the bathroom and experiences a spontaneous rupture of membranes.
What is the nurse’s priority action?

Choice A rationale

The term “passenger” in the context of the 5 P’s of labor refers to the fetus. The size, presentation, and position of the fetus can all affect the progress of labor. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to the fetus, so this is not the correct answer.

Choice B rationale

The term “passageway” refers to the birth canal, which includes the pelvis. The size and shape of the pelvis can greatly impact the progress of labor. If the provider comments that there is “plenty of room in the pelvis,” they are likely referring to the passageway. Therefore, this is the correct answer.

Choice C rationale

The term “powers” refers to the contractions during labor. The frequency, duration, and intensity of contractions can affect the progress of labor. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to contractions, so this is not the correct answer.

Choice D rationale

The term “position” refers to the mother’s position during labor. Different positions can help facilitate the progress of labor and can help with pain management. However, the provider’s comment about there being “plenty of room in the pelvis” does not directly relate to the mother’s position, so this is not the correct answer.

Choice A rationale

If a client reports feeling “down” and sad, having no energy, and wanting to cry, these could be signs of postpartum depression. It’s crucial to assess whether the client has considered harming her newborn, as this could indicate a severe form of postpartum depression that requires immediate intervention.

Choice B rationale

While anticipating a prescription for an antidepressant might be part of the treatment plan for postpartum depression, it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.

Choice C rationale

Assisting the family to identify prior use of positive coping skills in family crises could be helpful, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.

Choice D rationale

Reinforcing postpartum and newborn care discharge teaching is important, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.