A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?

Apply perineal pressure to the emerging fetal head

Cut the umbilical cord

Prevent the perineum from tearing

Promote delivery of the placenta

Answer and Explanation

The Correct Answer is A

A. Correct. In rapidly progressing labor, applying gentle perineal pressure helps control the speed of delivery and can prevent or minimize perineal tearing or lacerations. It also helps to manage the delivery of the fetal head, especially in cases where the labor is very rapid which can cause neurologic damage (increased intracranial pressure and dural/subdural tearing).

B. Cutting the umbilical cord is not the priority in this situation. The focus should be on the immediate management of the delivery process and preventing complications related to perineal tearing.

C. Preventing the perineum from tearing: While preventing the perineum from tearing is important, it is not the immediate priority in the context of rapidly progressing labor. The primary focus should be on safely delivering the baby, which involves controlling the delivery of the fetal head to prevent complications.

D. Promoting the delivery of the placenta is a consideration for the third stage of labor, which follows the delivery of the baby. It is not the priority during the active phase of delivery.

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Correct Answer is B

Explanation

A. Administering oxygen at 10 L/min via a nonrebreather mask is an important intervention, but changing the client's position is the priority action when late decelerations are observed. Oxygen administration can follow, but optimizing uteroplacental perfusion through changing position is crucial.

B. Changing the client's position is the correct first action.

Repositioning the client, particularly from a supine to a side-lying position, can help alleviate compression on the vena cava and improve blood flow to the uterus, reducing the likelihood of late decelerations.

C. Applying a fetal scalp electrode is not the initial action when late decelerations are noted. Repositioning the client should be attempted first to address potential issues related to uteroplacental perfusion.

D. Increasing the rate of the intravenous (IV) infusion might not directly address the issue of late decelerations. It's important to focus on maternal positioning first to improve blood flow to the uterus.

A. Administer oxygen to the client B. Turn the client onto her side C. Increase the client's IV fluid infusion rate D. Palpate the client's uterus

Correct Answer is B

Explanation

The correct answer is B. Turn the client onto her side.

A. Administering oxygen to the client is a reasonable intervention in the presence of late decelerations, but turning the client onto her side is the priority action to relieve potential compression of the vena cava and improve fetal oxygenation.

B. Turning the client onto her side is the correct first action.

Late decelerations are often associated with uteroplacental insufficiency. Changing the client's position, especially to the left lateral position, can help alleviate pressure on the vena cava, improving blood flow to the uterus and fetal oxygenation.

C. Increasing the client's IV fluid infusion rate may be considered, but it is not the first action to address late decelerations. Positioning changes should be initiated promptly.

D. Palpating the client's uterus is an assessment that may be done, but it is not the first action when late decelerations are observed. Positioning changes take precedence.

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A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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