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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Related Questions
Correct Answer is D
Explanation
A. Discuss contraceptive options with the client and her partner.Discussing contraceptive options typically occurs later in the postpartum period, often during follow-up visits. This is not a priority during the early taking-hold phase, when the mother is focused on learning to care for herself and her baby.
B. Repeat information to ensure client understanding.Repeating information and ensuring understanding is more critical during the taking-in phase, which occurs in the first 24 to 48 hours postpartum, when the mother is more passive, fatigued, and focused on her own recovery. In the taking-hold phase, the mother is typically more alert and eager to learn.
C. Listen to the client and her partner as they reflect upon the birth experience.Reflecting on the birth experience is more aligned with the taking-in phase, when the mother is focused on herself and may need emotional support in processing the experience.
D. Demonstrate to the client how to perform a newborn bath.In the taking-hold phase, the mother is ready to take responsibility for the care of her newborn and actively seeks guidance. Demonstrating how to bathe the newborn is an appropriate intervention, as it provides practical support and helps the mother gain confidence in newborn care.
Correct Answer is A
Explanation
The correct answer is A. Variable decelerations are due to umbilical cord compression.
A. Variable decelerations are often associated with umbilical cord compression. This compression can occur when the umbilical cord is briefly compressed or squeezed, leading to transient decreases in fetal heart rate.
B. Variable decelerations are not typically a result of the administration of IV narcotic analgesics. They are more commonly associated with cord compression or other factors affecting fetal oxygenation.
C. Variable decelerations are not generally caused by uteroplacental insufficiency. Uteroplacental insufficiency is more commonly associated with late decelerations.
D. Variable decelerations are not primarily related to fetal head compression. While head compression can cause certain types of decelerations, variable decelerations are specifically associated with umbilical cord compression.
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