A nurse is caring for a client at term in labor.
The client states, “I can’t do this anymore.”. She reports rectal pressure and increasing nausea. SVE (sterile vaginal exam) performed: 9 cm, 100% effaced, +1 station.
Encourage the client to continue pushing.
Prepare the client for delivery.
Administer pain relief as prescribed.
Reassure the client and provide emotional support.
The Correct Answer is B
Choice A rationale
Encouraging the client to continue pushing is not appropriate at this stage. The client is 9 cm dilated, which indicates that she is in the transition phase of labor, not yet fully dilated and ready to push. Pushing at this stage could cause cervical swelling and delay progress.
Choice B rationale
Preparing the client for delivery is the most appropriate action. The client is in the transition phase of labor, with 9 cm dilation, 100% effacement, and +1 station. This indicates that delivery is imminent, and the nurse should prepare for the birth process.
Choice C rationale
Administering pain relief as prescribed may be considered, but it is not the priority action at this stage. The client is in the transition phase, and administering pain relief could interfere with the natural progression of labor. Non-pharmacological support may be more appropriate.
Choice D rationale
Reassuring the client and providing emotional support is important, but it is not the primary action at this stage. The nurse should focus on preparing for delivery while also providing support and reassurance.
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Correct Answer is B
Explanation
Choice A rationale
Monitoring the patient’s vocalizations and facial expressions can provide some information about the intensity of contractions, but it is subjective and not a reliable method for accurately assessing contraction intensity.
Choice B rationale
Palpating the maternal abdomen during a contraction is the best method for determining the intensity of contractions. By feeling the firmness of the uterus, the nurse can assess whether the contractions are mild, moderate, or strong. This method provides a more objective measure of contraction intensity compared to other methods.
Choice C rationale
Timing the amount of time between the ending of one contraction and the beginning of the next provides information about the frequency of contractions, not their intensity. This choice does not address the question of how to determine contraction intensity.
Choice D rationale
Palpating the maternal abdomen right after a contraction does not provide information about the intensity of the contraction that just occurred. The uterus will be relaxed after the contraction, making it difficult to assess the strength of the previous contraction.
Correct Answer is B
Explanation
Choice A rationale
The presenting part being 2 cm below the ischial spines would be documented as +2 station, indicating that the fetal head is descending well into the pelvis.
Choice B rationale
The presenting part being 2 cm above the ischial spines is correctly documented as -2 station. This indicates that the fetal head is still relatively high in the pelvis and has not yet descended to the level of the ischial spines.
Choice C rationale
The presenting part being at the level of the ischial spines is documented as 0 station. This is the midpoint of the pelvis and indicates that the fetal head is engaged.
Choice D rationale
The presenting part being 2 cm below the cervix is not a standard way to describe fetal station. Station is measured relative to the ischial spines, not the cervix.