A nurse is caring for a client who is in active labor and notes persistent late decelerations on the fetal monitor.Which of the following are the priority nursing actions? (Select all that apply.)

Choice A rationale

Reassuring the client and rapidly completing the admission does not address the urgent symptom of an urge to have a bowel movement, which can indicate imminent delivery. Immediate assessment of labor progress is necessary.

Choice B rationale

Assisting the client to the bathroom to have a bowel movement may not be appropriate because the urge to defecate can signify the onset of the second stage of labor (pushing stage). Moving to the bathroom could risk an unattended delivery.

Choice C rationale

Assessing the fetal heart rate and uterine contractions with a routine tracing is important, but it does not directly address the urgent symptom of the urge to have a bowel movement. Vaginal exam takes priority to assess labor progress.

Choice D rationale

Assessing her progress of labor with a vaginal exam is the priority because the urge to have a bowel movement can signify that the baby is descending in the birth canal. This is the most immediate and necessary action to determine if delivery is imminent.

Choice A rationale

Documenting the findings in the client's medical record is important but is not the priority action when persistent late decelerations are noted. Immediate interventions are needed to improve fetal oxygenation.

Choice B rationale

Notifying the healthcare provider immediately is crucial as persistent late decelerations indicate fetal distress. The provider can decide on further interventions to ensure the safety of the mother and fetus.

Choice C rationale

Administering a tocolytic medication to stop contractions is not appropriate in this scenario. The priority is to improve fetal oxygenation, not to stop contractions.

Choice D rationale

Repositioning the client to a side-lying position can help improve blood flow to the uterus and placenta, enhancing fetal oxygenation. This is a priority intervention.

Choice E rationale

Administering pain medication to the client is not a priority in this situation. The focus should be on addressing fetal distress and improving oxygenation.

Choice F rationale

Administering oxygen to the client increases the oxygen available to the fetus and is a priority intervention when persistent late decelerations are noted.