A nurse has assessed a patient in labor.
The patient’s cervix is dilated 4 cm and 100% effaced.
The fetus is in the vertex presentation at -1 station.
The patient is walking to the bathroom and experiences a spontaneous rupture of membranes.
What is the nurse’s priority action?

Choice A rationale

Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.

Choice B rationale

Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.

Choice C rationale

Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.

Choice D rationale

Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.

Choice A rationale

Administering oxygen via face mask is a common intervention for many complications during labor. However, it is not the first-line intervention for late decelerations. Late decelerations are a sign of fetal distress, often due to uteroplacental insufficiency. While oxygen can help increase oxygenation to the fetus, it does not address the root cause of the problem.

Choice B rationale

Elevating the patient’s legs is not typically the priority action when late decelerations are noted. This action would not alleviate the cause of late decelerations.

Choice C rationale

Having the patient turn to a side-lying position is often the first intervention when late decelerations are noted. This position helps increase blood flow to the placenta, potentially alleviating uteroplacental insufficiency and improving fetal oxygenation.

Choice D rationale

Increasing the infusion rate of IV fluids is not the first-line intervention for late decelerations. While it may be part of the management plan, it is not the priority action.