A woman is in the second stage of labor with a strong urge to push.
Which of the following actions by the nurse is appropriate at this time?
Call and notify the provider the patient would like to push.
Perform a sterile vaginal exam (SVE).
Give supportive words and care to comfort the patient during labor.
Monitor the fetal heart rate tracing for signs of fetal intolerance to labor.
The Correct Answer is B
Choice A rationale
Notifying the provider is important but does not address the immediate need to assess the patient's progress and readiness for delivery. A direct intervention is required to determine the next steps.
Choice B rationale
Performing a sterile vaginal exam allows the nurse to assess cervical dilation and effacement, fetal station, and presentation, which are crucial to determine if the patient is ready to push and proceed with delivery.
Choice C rationale
Supportive words and care are essential for patient comfort, but they do not provide the necessary assessment to determine the patient's progress in labor or readiness for pushing.
Choice D rationale
Monitoring the fetal heart rate tracing is important for assessing fetal well-being but does not specifically address the patient's readiness to push or her labor progress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is True
Explanation
Choice A rationale
Starting Pitocin at a low dose minimizes the risk of uterine hyperstimulation, which can cause fetal distress. Gradually increasing the dose allows careful monitoring of the mother’s and fetus’s responses for optimal contraction rate.
Choice B rationale
Administering Pitocin without starting at a low dose increases the risk of uterine tachysystole, leading to potential complications like uterine rupture or placental abruption. A gradual increase ensures safer labor progression.
Correct Answer is C
Explanation
Choice A rationale
Placental uterine insufficiency causes late decelerations, not early decelerations. Late decelerations indicate decreased placental perfusion and inadequate fetal oxygenation.
Choice B rationale
Umbilical cord compression leads to variable decelerations, characterized by abrupt decreases in fetal heart rate. Early decelerations are unrelated to cord compression.
Choice C rationale
Early decelerations are caused by head compression during contractions. This reflex response results in vagal stimulation and a uniform, gradual decrease in fetal heart rate, mirroring contractions.
Choice D rationale
Spontaneous rupture of membranes can influence labor progress but does not cause early decelerations. Early decelerations are primarily associated with head compression during contractions.
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