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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Contractions lasting longer than 90 seconds.
A. Contractions lasting longer than 90 seconds can be indicative of a prolonged contraction, which may affect uteroplacental perfusion and fetal oxygenation. This is a concern and should be reported to the provider.
B. Contractions occurring every 3 to 5 minutes are within the normal frequency range during the active phase of the first stage of labor.
C. The client reporting feeling contractions in the lower back is a common description of back labor, which may occur due to the position of the baby. It is not necessarily a cause for immediate concern unless it is associated with other issues.
D. Contractions being strong in intensity is expected during the active phase of labor. Strong contractions are necessary for cervical dilation and the progression of labor.
Correct Answer is D
Explanation
The correct answer is D. Prolonged labor
A. Umbilical cord prolapse is more commonly associated with breech presentations or other abnormal fetal positions. It is not a typical complication of occipital brow presentation.
B. Precipitous labor refers to an unusually rapid labor, and it is not a typical complication associated with occipital brow presentation. Prolonged labor is more likely.
C. Hypertonic uterine dysfunction involves excessive uterine contractions, and it is not specifically associated with occipital brow presentation. It is more commonly associated with other factors, such as maternal anxiety or use of oxytocin.
D. Prolonged labor is a complication that can be associated with occipital brow presentation.
Occipital brow presentation involves the fetal head being partially extended, and it can lead to difficulties in descending through the birth canal. This may result in a prolonged labor process.
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