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

The correct answer is B. Just above the symphysis pubis.

A. Just above the umbilicus: At the end of the first trimester, the uterus is still within the pelvic cavity, and fetal heart tones are typically not detectable above the umbilicus at this stage.

B. Just above the symphysis pubis: This is the correct placement for assessing fetal heart tones during the first trimester. The fetal heart is usually located low in the pelvis during early pregnancy, making it most easily heard just above the pubic bone.

C. The right lower quadrant: Fetal heart tones are typically assessed in the midline of the abdomen, and focusing on the lower quadrants may not be the optimal location, especially in the first trimester.

D. The left lower quadrant: Similar to the right lower quadrant, focusing on the lower quadrants may not be the most appropriate location for assessing fetal heart tones during the first trimester.

A. Decreased vaginal discharge B. Weight gain of 0.5 to 1,5 kg C. Urinary retention D. A surge of energy

Correct Answer is D

Explanation

A. Decreased vaginal discharge is not typically associated with the onset of labor. In fact, an increase in vaginal discharge may be observed as the cervix begins to soften and efface.

B. Weight gain of 0.5 to 1.5 kg is not a specific sign that precedes labor. Weight gain during late pregnancy is more related to fluid retention, and it does not necessarily indicate imminent labor.

C. Urinary retention is not a common sign that precedes labor. However, increased pressure on the bladder from the descending fetus may lead to more frequent urination rather than retention.

D. A surge of energy is known as the "nesting instinct" and is a common sign that precedes labor. Some women experience a burst of energy and motivation to prepare for the upcoming birth.

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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?

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Naxlex Comprehensive Predictor Exams

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