A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 6 cm, 90% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is clear. What action should the nurse take next?

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take next is to monitor the fetal heart rate pattern. This is crucial as the client is in active labor, and monitoring the fetal heart rate helps assess the well-being of the fetus during this critical stage. Performing a vaginal examination (Option B) may increase the risk of infection since the membranes have already ruptured. Encouraging the client to ambulate (Option C) may not be suitable at this point due to the stage of labor and the need for continuous monitoring. Administering pain medication (Option D) could be considered based on the client's pain level, but ensuring fetal well-being through continuous fetal heart rate monitoring takes precedence in this situation. From an educational standpoint, understanding the significance of fetal heart rate monitoring in labor is crucial for ensuring optimal maternal and fetal outcomes. It allows for early identification of any potential issues, enabling prompt intervention if needed. Students and healthcare providers must prioritize fetal assessment during labor to provide safe and effective care for maternal and reproductive health clients.

Correct Answer: A

Rationale: In this scenario, the most appropriate action for the nurse to take first is to assess the fetal heart rate pattern (Option A). This is crucial because the greenish-brown amniotic fluid indicates meconium-stained amniotic fluid, which can be a sign of fetal distress. By assessing the fetal heart rate, the nurse can determine the well-being of the fetus and make timely decisions regarding further interventions. Performing a vaginal examination (Option B) may not be the priority at this moment as assessing the fetal well-being takes precedence. While preparing for an emergency cesarean section (Option C) may be necessary if there are signs of fetal distress, it is important to first assess the fetal heart rate to confirm the need for immediate surgical intervention. Administering oxygen via face mask (Option D) may be indicated later based on the fetal heart rate assessment but is not the first action to take in this situation. In an educational context, this question highlights the importance of prompt assessment and intervention in cases of meconium-stained amniotic fluid during labor. It emphasizes the critical role of fetal monitoring in ensuring the well-being of both the mother and the baby during the labor and delivery process.

Correct Answer: A

Rationale: In this scenario, the correct action the nurse should anticipate is the administration of prostaglandin gel (Option A). This is because the client's Bishop score of 4 indicates an unfavorable cervix for induction. Prostaglandin gel helps ripen the cervix, making it softer and more favorable for labor induction. This can increase the likelihood of a successful vaginal delivery. Option B, rupture of membranes, would not be appropriate at this stage as the cervix is not yet favorable, and this intervention could increase the risk of complications without promoting labor progression. Option C, administration of oxytocin, would not be the first choice in this situation since the client's cervix is unfavorable for induction. Oxytocin is usually used once the cervix has ripened and labor is progressing. Option D, preparation for a cesarean section, is not warranted at this point since the client is being admitted for induction of labor, not for a cesarean section. It is essential to exhaust conservative measures for labor induction before considering a cesarean section. In an educational context, understanding the Bishop score and the implications for labor induction is crucial for nurses caring for maternal and reproductive health clients. It helps them make informed decisions based on the client's individual circumstances to optimize outcomes for both the client and the baby.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take is to encourage the client to pant-blow during contractions (Option A). Pant-blowing is a technique used during the second stage of labor to prevent rapid pushing, which can lead to maternal exhaustion, fetal distress, and perineal trauma. By encouraging the client to pant-blow, the nurse helps control the pushing efforts, allowing for controlled and effective pushing during contractions. Assisting the client to push with contractions (Option B) would not be appropriate in this case as the client is already pushing forcefully, and further pushing could lead to complications as mentioned earlier. Preparing for an immediate delivery (Option C) is premature at this stage since the client is only 7 cm dilated, and the fetus is at +1 station. It is essential to allow the labor to progress further before preparing for delivery. Notifying the healthcare provider (Option D) is not necessary at this moment as the situation is within the realm of normal labor progress. The nurse can manage the client's pushing technique effectively without the need for immediate provider intervention. Educationally, understanding the appropriate pushing techniques during labor is crucial for maternal and fetal well-being. Nurses need to be knowledgeable about guiding clients in effective pushing methods to ensure optimal outcomes during the childbirth process.

Correct Answer: D

Rationale: In this scenario, the most important action for the nurse to take is to provide clear concise instructions in a calm, deliberate manner (Option D). This is the correct answer because effective communication is crucial in emergency situations. By remaining calm and providing clear instructions, the nurse can help reassure the pregnant woman, maintain a sense of control, and guide her through the delivery process until medical help arrives. Option A, determining the gestational age of the fetus, is not the most immediate concern in this urgent situation. Assessing the amount and color of the amniotic fluid (Option B) is also important but not as critical as ensuring clear communication with the patient. Similarly, obtaining IV access and starting IV fluids (Option C) can be important but should not take precedence over providing immediate support and instructions to the woman in labor. In an educational context, this question highlights the significance of effective communication and quick decision-making in emergency obstetric care. Nurses need to be prepared to handle unexpected situations with composure and clarity to ensure the safety and well-being of both the mother and the baby. Training in emergency obstetric care equips healthcare providers with the skills needed to respond promptly and appropriately in high-stress situations like imminent deliveries.