QUESTION: "The nurse determines that a multigravid client in active labor is about to deliver. The nurse has no help immediately available. Which of the following should the nurse do first?"
CHOICES
( X ) a.) Have the client push with a contraction.
( X ) b.) Ask the client to take a deep breath and hold it.
( O ) c.) Prepare a clean area on which to deliver the neonate.
( X ) d.) Lower the head of the bed to a flat position.
RATIONALE: Because the birth is imminent and no additional help is available, the nurse should immediately prepare a clean area for delivery. Most agency labor units have emergency delivery packs with sterile towels, a bulb syringe, and a cord clamp. Having the client push with a contraction may push the head out quickly, resulting in tearing of the perineum. The nurse should instruct the client to pant or pant:blow to decrease the urge to push. Trying to delay the birth is contraindicated. The head of the bed should be elevated to about 45%, not lowered. The client should assume a position of comfort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
