A patient presents to the labor and birth area for emergent birth. Vaginal exam reveals that the patient is fully dilated, vertex, +2 station, with ruptured membranes. The patient is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this patient assessment?

Correct Answer: A

Rationale: The correct answer is A because the patient is fully dilated and at +2 station, indicating imminent birth. Administering an epidural at this stage can be risky due to the potential for rapid progression of labor, making it difficult to safely place the epidural. Contact anesthesia is often used in emergent situations for epidural placement. Additionally, preparing the patient per protocol ensures that all necessary steps are followed for the safety and well-being of the patient and the baby. Choices B and C are incorrect because telling the patient she won't need pain medication is dismissive of her valid request and could lead to unnecessary distress. Assisting with nonpharmacologic methods may not be effective at this point given the patient's extreme apprehension and the advanced stage of labor. Choice D is incorrect as calling the physician for admitting orders is not the priority in this situation. The immediate focus should be on addressing the patient's request for pain management and ensuring her safety during the birth process.

Correct Answer: C

Rationale: The correct answer is C because the patient is dilated at 2 cm and 80% effaced, indicating early labor. This stage allows for the patient to be receptive to learning about nonpharmacologic pain control methods. The other choices are incorrect because they are in active labor or experiencing intense pressure, making it less ideal for teaching nonpharmacologic methods.

Correct Answer: B

Rationale: The correct answer is B: Maternal temperature. The priority assessment before using jet hydrotherapy is to check the maternal temperature to ensure it is within normal limits. Elevated temperature can indicate infection, which could be exacerbated by hydrotherapy. Maternal pulse (A), blood pressure (C), and blood glucose level (D) are important assessments but are not the priority before using hydrotherapy. Pulse and blood pressure can be monitored during hydrotherapy, and blood glucose levels are typically not affected by hydrotherapy.

Correct Answer: A

Rationale: The correct answer is A because administering a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement helps prevent hypotension, a common side effect of epidural anesthesia. This bolus helps maintain adequate fluid volume, which is crucial for hemodynamic stability during the procedure. Choice B is incorrect because having ephedrine available is not a necessary intervention for preparing a patient for epidural placement. Choice C is incorrect because while monitoring blood pressure is important during epidural administration, it should be done continuously rather than just for the first 15 minutes. Choice D is incorrect because inserting a Foley catheter is not a routine intervention for epidural catheter placement and is not directly related to the procedure's success or safety.

Correct Answer: C

Rationale: The correct answer is C: Administer a normal saline bolus as prescribed. In this scenario, hypotension post-epidural could be due to vasodilation leading to decreased blood pressure. Administering a normal saline bolus can help increase intravascular volume and improve blood pressure. Encouraging the patient to drink fluids (A) may not provide immediate volume resuscitation. Placing the patient in a Trendelenburg position (B) can worsen hypotension by increasing pressure on the vena cava. Administering oxygen (D) may be helpful but addressing the hypotension with a saline bolus is the priority.