During a vaginal delivery, the first thing a nurse must ensure when the head comes out is that the midwife or doctor checks that

Choice A reason:

This is the best response because it shows that the nurse is providing nonpharmacological pain relief measures and supporting the client's coping mechanisms. Breathing and imagery techniques can help the client relax and focus on something other than the pain. Moaning, screaming, and vocalizing are normal and acceptable ways of expressing pain during labor, and the nurse should not try to suppress them.

Choice B reason:

This is not the best response because it does not address the husband's concern or offer any intervention for the client's pain. Asking the client to rate her pain on a scale of 0 to 10 is a subjective assessment tool that may not reflect the true intensity of her pain. Furthermore, it may be difficult for the client to answer this question while she is in the second stage of labor.

Choice C reason:

This is not the best response because it may not be feasible or appropriate to administer more pain medication to the client in the second stage of labor. The obstetrician may not be available to evaluate the client's pain, and increasing the dose of pain medication may have adverse effects on the client and the fetus, such as respiratory depression, hypotension, and decreased uterine contractility.

Choice D reason:

This is not the best response because it does not acknowledge the husband's feelings or provide any comfort or education for him. Reassuring him that his wife will be fine may sound dismissive and insensitive, and offering to stay with her while he takes a walk may imply that he is not needed or wanted in the birthing room. The nurse should involve the husband in the care of his wife and explain to him what is happening and what to expect during labor.

A. Right occiput posterior position: This position refers to the baby's head being down but facing the mother's back, which can make labor more challenging but is not a contraindication for amniotomy.

B. -2 station: This indicates that the baby's head is not yet engaged in the pelvis. While it can complicate labor, it is not an absolute contraindication for amniotomy, though caution is advised.

C. Cephalic presentation: This is the most common and favorable position for delivery, where the baby's head is down and ready for birth. It is not a contraindication for amniotomy.

D. Dilation less than 3 cm: This is a contraindication for amniotomy because the cervix is not sufficiently dilated, which can increase the risk of complications such as infection or prolonged labor.