A nurse is caring for a client who is in the first stage of labor.
The nurse observes the umbilical cord protruding from the vagina.
Which of the following actions should the nurse NOT perform?

Choice A rationale

Administering oxytocin is not appropriate at this stage since the fetal head at a +5 station indicates imminent delivery.

Choice B rationale

Applying fundal pressure is not recommended and can cause complications such as uterine rupture or maternal injury.

Choice C rationale

Suctioning the mouth of the infant at the perineum should be done only after the head is delivered to clear airway obstructions.

Choice D rationale

Observing for the presence of a nuchal cord is crucial as it can cause complications during delivery, requiring immediate attention.

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.