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 A

Explanation

A. "This medication promotes softening of the cervix."

A. Dinoprostone is a prostaglandin E2 analogue that is used to ripen the cervix by promoting softening and effacement. This is an important step in preparing the cervix for labor induction or augmentation.

B. Dinoprostone does not cause relaxation of the uterine muscles. Instead, it specifically works on the cervix to make it more favorable for labor.

C. Dinoprostone is not used to treat preeclampsi

A. It is primarily used for cervical ripening in the context of labor induction or augmentation.

D. Dinoprostone is not used to treat genital herpes simplex virus. It is specifically employed for its effects on cervical ripening and preparing the cervix for labor.

A. Hgb 20 g/dL B. Total bilirubin 5 mg/dL C. Blood glucose 30 mg/dL D. WBC count 20.000/mm3

Correct Answer is C

Explanation

Choice A Reason:

Hemoglobin (Hgb) of 20 g/dL is elevated, but this can be a normal finding in a newborn and does not necessarily require immediate intervention.

Choice B Reason:

Total bilirubin of 5 mg/dL is within the normal range for a 24-hour-old newborn.

Choice C Reason:

Blood glucose 30 mg/dL. A blood glucose level of 30 mg/dL is significantly lower than the normal range for a newborn. Hypoglycemia in a newborn can lead to neurologic complications, so it is important to report this result promptly for further evaluation and intervention.

Choice D Reason:

White blood cell (WBC) count of 20,000/mm³ is within the expected range for a newborn and is not a cause for immediate concern. Newborns often have higher WBC counts shortly after 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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