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 B
Explanation
A. "This medication will stop your labor": Betamethasone is not intended to stop labor. It is given to promote fetal lung maturity and reduce the risk of complications associated with preterm birth.
B. "This medication stimulates fetal lung maturity": This is the correct statement. Betamethasone is administered to enhance the production of surfactant in the fetal lungs, improving respiratory outcomes for the preterm infant.
C. "This medication will decrease your risk for uterine infections": Betamethasone does not directly decrease the risk of uterine infections. Its primary benefit is in promoting fetal lung maturity.
D. "This medication will increase your baby's weight": Betamethasone is not given to increase the baby's weight. Its main focus is on improving lung function and reducing respiratory complications in preterm infants.
Correct Answer is C
Explanation
A. The pattern of contractions is important in assessing labor, but the presence of regular contractions alone does not confirm true labor. It is the changes in the cervix that indicate progress in labor.
B. The station of the presenting part (the level at which the baby's head has descended into the pelvis) is also a factor in labor, but it is not the primary indicator of true labor. Changes in the cervix are more indicative.
C. Changes in the cervix are a key sign of true labor.
True labor involves cervical effacement (thinning) and dilation (opening). These changes in the cervix signify progress in the labor process.
D. Rupture of the membranes (water breaking) can be a sign of labor, but it doesn't confirm true labor on its own. It might occur before, during, or after labor has begun.
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