A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

Choice A rationale:

The priority nursing action after an amniotomy is to ensure the well-being of both the mother and the baby. While evaluating the client for signs of infection is important, it is not the immediate priority. Infection can be a concern after any invasive procedure, but checking the fetal heart rate pattern takes precedence to assess the baby's condition immediately after the amniotomy.

Choice B rationale:

Checking the fetal heart rate pattern is the priority because it helps to monitor the baby's well-being and detect any signs of fetal distress. Amniotomy is the artificial rupture of the amniotic membrane, and it can sometimes lead to changes in the baby's heart rate, which may indicate distress or other complications. Identifying and addressing these changes

promptly is crucial for the baby's safety.

Choice C rationale:

Observing the color and consistency of amniotic fluid is essential to assess for any abnormalities or meconium staining, which could indicate fetal distress or potential issues. However, this action should follow the immediate concern of checking the fetal heart rate pattern since fetal distress takes priority over amniotic fluid characteristics.

Choice D rationale:

Taking the client's temperature is important, but it is not the priority immediately after an amniotomy. Monitoring the client's temperature is a routine nursing action to detect any signs of infection. However, the priority in this situation is to ensure the baby's well-being through fetal heart rate assessment.

Choice A rationale:

Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labour, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.

Choice B rationale:

Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.

Choice C rationale:

Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labour has commenced. Panting is not necessary at this point.

Choice D rationale:

The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.