QUESTION: "The multigravid client with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" Which of the following would be the nurse's first action?"
CHOICES
( O ) a.) Inspect the perineum.
( X ) b.) Time the contractions.
( X ) c.) Auscultate the fetal heart rate.
( X ) d.) Contact the birth attendant.
RATIONALE: When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the client's statement. If the client is not delivering precipitously, the nurse can calm her and use appropriate breathing techniques. Timing contractions is not the priority action. The nurse needs to determine if what the client says is accurate. Monitoring the fetal heart rate, including auscultation, occurs throughout the labor process. The nurse should try to obtain assistance if delivery is imminent, but the nurse should never leave the client. Delivery may occur before the physician arrives. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
