A nurse is assisting with the care of a client who is in labour and has an external electronic fetal monitor. The nurse observes that the fetal heart rate begins to decelerate after the contraction has started, with the lowest point of the deceleration occurring after the peak of the contraction. Which of the following actions should the nurse take first?

Choice D rationale:

The nurse should state, "The purpose of this medication is to boost fetal lung maturity.”. The rationale behind this choice is that betamethasone is a corticosteroid medication commonly administered to women at risk of preterm delivery between 24 and 34 weeks of gestation. Its primary goal is to accelerate fetal lung maturation by promoting the production of surfactant, a substance that coats the lungs and prevents their collapse. By enhancing lung development, the medication helps reduce the risk of respiratory distress syndrome and other respiratory complications that premature infants might face. It does not directly impact fetal heart rate (Choice A), halt cervical dilation (Choice B), or stop preterm labor contractions (Choice C).

Choice A rationale:

The nurse should not state, "The purpose of this medication is to increase the fetal heart rate.”. Betamethasone does not affect the fetal heart rate, as it is primarily used to enhance lung maturity, as mentioned earlier. The incorrect statement may lead to confusion and misunderstanding of the medication's intended purpose.

Choice B rationale:

The nurse should not state, "The purpose of this medication is to halt cervical dilation.”. Betamethasone does not stop or halt cervical dilation. Its main action is on the fetal lungs to promote surfactant production. Cervical dilation is a natural process that occurs during labor and is not influenced by this medication.

Choice C rationale:

The nurse should not state, "The purpose of this medication is to stop preterm labor contractions.”. Betamethasone is not used to stop or prevent preterm labor contractions directly. Instead, its focus is on improving fetal lung maturity to enhance the baby's respiratory function once born prematurely.

Choice A rationale:

Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labor, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.

Choice B rationale:

Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.

Choice C rationale:

Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labor has commenced. Panting is not necessary at this point.

Choice D rationale:

The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.