A nurse is assisting with the care of a client who presents to a labor and delivery unit with rapidly progressing labor. Which of the following actions is the priority for the nurse to take?
Supporting the infant during the birth.
Preventing the perineum from tearing.
Cutting the umbilical cord.
Promoting delivery of the placenta.
The Correct Answer is A
Choice A rationale:
Supporting the infant during birth. The priority for the nurse in this situation is to ensure the safe delivery of the baby. By supporting the infant during birth, the nurse can help ensure that the baby is delivered safely and efficiently. This involves assisting the mother in pushing and guiding the baby's head and body as it emerges from the birth canal. The nurse should also be ready to catch the baby and provide immediate care, such as drying and stimulating the baby to breathe if necessary.
Choice B rationale
Preventing the perineum from tearing. While preventing perineal tearing is important, it is not the top priority in this rapidly progressing labor scenario. The immediate concern is the safe delivery of the baby, and if perineal tearing does occur, it can be addressed after the birth.
Choice C rationale
Cutting the umbilical cord. This action is necessary but not the top priority. After the baby is delivered, the nurse should clamp and cut the umbilical cord to separate the baby from the placenta. However, this can wait until the baby is fully delivered and breathing on their own.
Choice D rationale
Promoting delivery of the placenta. Again, while delivering the placenta is important to prevent postpartum haemorrhage, it is not the priority in this scenario. The nurse's immediate focus should be on supporting the infant's delivery and ensuring the baby's well-being.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The nurse should monitor the urinary output of the client as it can be an important indicator of hydration and renal function. However, in this specific scenario, the administration of oxytocin via IV infusion after a vaginal delivery requires a different focus for evaluating medication effectiveness.
Choice B rationale:
The nurse should primarily assess the fundal consistency to evaluate the effectiveness of oxytocin. Oxytocin is often administered after childbirth to promote uterine contractions and prevent postpartum hemorrhage. Checking the fundal consistency helps determine if the uterus is contracting appropriately. A firm fundus indicates effective contractions, which are essential for controlling bleeding and preventing complications.
Choice C rationale:
Monitoring the pulse rate is a vital aspect of patient care, but it may not be the most relevant parameter to evaluate the effectiveness of oxytocin. Pulse rate can give information about the client's cardiovascular status and general well-being, but it does not directly assess the medication's impact on uterine contractions.
Choice D rationale:
Similarly, keeping an eye on blood pressure is crucial for patient safety and detecting potential issues like hypertension. However, it is not the primary parameter for evaluating the effectiveness of oxytocin. Blood pressure monitoring is essential for overall health assessment but does not directly relate to the medication's intended effect.
Correct Answer is D
Explanation
The correct answer is choice d. Place the client in a knee-chest or Trendelenburg position.
Choice A rationale:
Preparing the client for an emergency cesarean birth is important, but it is not the immediate first action. The priority is to relieve pressure on the umbilical cord to prevent fetal hypoxia.
Choice B rationale:
Explaining to the client what is happening is important for communication and reassurance, but it is not the immediate first action. Immediate physical intervention is required to prevent harm to the fetus.
Choice C rationale:
Covering the cord with a sterile, moist saline dressing is a necessary step to prevent the cord from drying out and to reduce infection risk, but it should be done after repositioning the client to relieve pressure on the cord.
Choice D rationale:
Placing the client in a knee-chest or Trendelenburg position helps to relieve pressure on the umbilical cord, which is crucial to maintain fetal oxygenation. This is the immediate first action to take in this emergency situation.
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