A nurse is caring for a client who is in active labor.
The nurse notes late decelerations in the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take first?

Choice A rationale: Verifying that the client has signed an informed consent form is essential before initiating cervical ripening with prostaglandins. Dinoprostone insertion is an invasive procedure with potential risks such as uterine tachysystole, fetal distress, or the need for cesarean delivery. Informed consent ensures that the client understands the risks, benefits, and alternatives, and it fulfills both ethical and legal requirements. Therefore, this intervention must be included in the plan of care prior to medication administration.

Choice B rationale: Terbutaline, a beta-adrenergic agonist, must be readily available because prostaglandins can cause uterine tachysystole or hyperstimulation, which compromises uteroplacental blood flow and fetal oxygenation. Terbutaline relaxes uterine smooth muscle, reversing hyperstimulation and preventing fetal hypoxia. Having this medication immediately accessible is a critical safety measure during induction. This aligns with the provider’s order to notify for tachysystole or nonreassuring FHR and ensures rapid intervention if complications arise.

Choice C rationale: Maintaining bed rest for 2 hours after prostaglandin administration is not recommended. The correct evidence-based practice is to keep the client in a side-lying or supine position with a wedge for 30 to 60 minutes to allow absorption of the medication and reduce the risk of expulsion. Prolonged bed rest beyond this period is unnecessary and increases the risk of venous thromboembolism. Therefore, this intervention is not appropriate for the plan of care.

Choice D rationale: Dinoprostone (Cervidil, Prepidil) is a prostaglandin E2 analog that requires refrigeration to maintain stability and potency. The medication should be kept refrigerated until just before administration to ensure effectiveness. Improper storage at room temperature for extended periods can degrade the drug, reducing its efficacy in cervical ripening. Therefore, refrigeration until administration is a correct nursing intervention and should be included in the plan of care.

Choice E rationale: Assisting with an amniotomy before prostaglandin placement is not appropriate. Prostaglandins are used to ripen the cervix before oxytocin induction, and amniotomy is typically performed later to augment labor once the cervix is favorable. Performing an amniotomy prematurely increases the risk of infection, cord prolapse, and fetal distress. Since the membranes are intact and the cervix is closed and thick, prostaglandin ripening is indicated first, not amniotomy.

Choice F rationale: Keeping calcium gluconate at the bedside is necessary when administering magnesium sulfate, not prostaglandins. Calcium gluconate is the antidote for magnesium toxicity, which causes respiratory depression and cardiac complications. Since this client is not receiving magnesium sulfate, calcium gluconate is not relevant to the current plan of care. Therefore, this intervention is not appropriate in this context.

Choice G rationale: Having the client void before insertion of the prostaglandin is correct. An empty bladder reduces the risk of bladder injury during insertion, improves maternal comfort, and prevents urinary retention while the client remains in the side-lying position for 30 to 60 minutes after administration. This intervention is specifically ordered by the provider and is a standard nursing action to optimize safety and comfort during cervical ripening.

Choice A rationale

Sequential compression devices (SCDs) are applied preoperatively to promote venous return and prevent venous stasis in the lower extremities, significantly reducing the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE), which are critical concerns during and after major surgery like a cesarean birth. Prophylaxis should commence before the operation for maximal effect.

Choice B rationale

An indwelling urinary catheter is typically inserted prior to the cesarean section, after the client receives regional anesthesia, to ensure the bladder is empty during the procedure, preventing injury to the bladder by the surgeon and maintaining a clear surgical field. It is not delayed until immediately following the procedure.

Choice C rationale

Oxytocin is a uterotonic agent administered post-delivery of the placenta (not prior to the procedure) via continuous IV infusion to stimulate uterine contractions, which is crucial for preventing postpartum hemorrhage by promoting myometrial contraction and vessel constriction.

Choice D rationale

The surgical timeout, a critical patient safety measure that verifies the correct patient, procedure, and surgical site, is performed by the entire surgical team immediately prior to the incision, typically after the client enters the operating room and is prepped, not while they are in the preoperative holding area.