A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

Assist the client into a comfortable position.

Observe the perineum for signs of crowning.

Have the client pant during the next contractions.

Help the client to the bathroom to void.

None

Answer and Explanation

The Correct Answer is C

Choice A reason:

While positioning is important for comfort during labor, addressing the immediate urge to push takes priority. Panting during contractions is the appropriate action.

Choice B reason:

Although observing for crowning is important when the client is close to delivery, the nurse should first intervene to address the client's urge to push since the client is only 7 cm dilated.

Choice C reason:

When a laboring client feels the urge to push but is not yet fully dilated (10 cm), encouraging her to pant can help reduce the urge to push and avoid complications, such as cervical swelling or tearing. This breathing technique helps the client delay pushing until full dilation and readiness of the cervix.
Choice D reason:

Assisting the client to the bathroom would not be appropriate at this stage of labor because the urge to push could lead to unsafe delivery outside the appropriate setting, and movement could increase discomfort or risks.

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Correct Answer is B

Explanation

Choice A reason:

Changing the patient's gown may be necessary for comfort and hygiene, but it is not the priority after an amniotomy. The main concern is the well-being of the fetus and the mother.

Choice B reason:

Assessing the fetal heart rate is the priority after an amniotomy. This procedure involves rupturing the amniotic sac, which may lead to changes in the fetal environment. Monitoring the fetal heart rate helps determine if the baby is tolerating the procedure well and if there are any signs of distress.

Choice C reason:

Estimating the amount of amniotic fluid is essential during an amniotomy, but it is not the top priority. The focus should be on evaluating the fetal well-being first.

Choice D reason:

Assessing the color of the amniotic fluid is significant, but it is not the primary concern immediately after an amniotomy. While changes in fluid color may indicate certain conditions, the fetal heart rate assessment takes precedence in this situation.

A. Rupture of the membranes. B. Pattern of contractions. C. Changes in the cervix. D. Station of the presenting part.

Correct Answer is C

Explanation

Choice A reason:

Rupture of the membranes is not a reliable sign of true labor, as it can occur before or during labor, or be artificially induced by the provider. • Choice B reason:

Patterns of contractions can vary depending on the stage and phase of labor, and can also be influenced by factors such as hydration, activity, and medication. Contractions alone do not indicate true labor unless they are accompanied by cervical changes. • Choice C reason:

Changes in the cervix, such as effacement (thinning) and dilation (opening), are the most accurate indication of true labor. Cervical changes are caused by the pressure of the presenting part and the force of the contractions. The nurse should assess the cervix periodically to determine the progress of labor. • Choice D reason:

The station of the presenting part refers to the relationship of the fetal head to the maternal ischial spines, which are bony landmarks in the pelvis. The station can range from -5 (high) to +5 (low), with 0 being at the level of the ischial spines. Station does not indicate true labor, as it can vary depending on the parity, pelvic shape, and fetal position of the client.

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A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

After an amniotomy, which action by the nurse takes priority?

Correct Answer is B

Explanation

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not.”. Which of the following should the nurse recognize as a sign of true labor?

Correct Answer is C

Explanation

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