A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

Choice A Reason:

Oxygen Saturation: While oxygen saturation is important, it is not the highest priority assessment related to amniotomy. Monitoring oxygen levels is crucial during labor, but other factors take precedence

Choice B Reason:

Temperature:Correct. The nurse should prioritize monitoring the client’s temperature following an amniotomy. If the patient’s temperature is38°C (100.4°F) or higher, the nurse needs to notify the primary care physician promptly. Elevated temperature can indicate infection, which is a significant concern after the rupture of membranes.The nurse should also assess for other signs of infection, such as chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.

Choice C Reason:

Blood pressure is incorrect. Blood pressure is an essential parameter to monitor during labor, but it may not be the immediate priority when planning an amniotomy. Oxygen saturation takes precedence as it provides more direct information about the oxygenation status of both the mother and the fetus.

Choice D Reason:

Urinary output is incorrect. Urinary output is a vital sign to monitor, but it may not be the immediate priority when preparing for an amniotomy. O2 saturation is more directly relevant to the potential effects on the fetus during this intervention.

A. Instructing the client to increase her respiratory rate to more than 42 breaths per minute may exacerbate hyperventilation and cause respiratory alkalosis. This is not the appropriate action in this situation.

B. Breathing into a paper bag is an outdated and potentially dangerous practice. It can lead to a buildup of carbon dioxide in the body and may have adverse effects on both the mother and the baby. It is not recommended.

C. Having the client tuck her chin to her chest is the correct action.

This maneuver helps decrease the respiratory rate and prevent hyperventilation. It promotes a controlled and appropriate breathing pattern during labor.

D. Administering oxygen via nasal cannula is not the first-line intervention for lightheadedness and tingling during labor. The client's symptoms are likely due to hyperventilation, and addressing the breathing pattern is more appropriate.