A nurse is caring for a client who is nulliparous and in the first stage of labor. The last
internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?

A. Inform the client of available community resources is an important action because the client will likely need additional support, such as hospice care, counseling, or child care services. However, before providing resources, the nurse must assess the client’s understanding of their diagnosis to ensure any interventions are tailored to their current needs and readiness.

B. Assist the client in finding child care options - While important, addressing community resources takes precedence as it may encompass finding child care options as well.

C. Agree upon short-term goals for the client - Establishing goals is important but may come after addressing immediate needs.

D. Ask the client about their understanding of the diagnosis is the priority action. Before any other interventions, the nurse must assess the client’s knowledge and perception of their condition. This foundational step allows the nurse to provide appropriate education, clarify any misconceptions, and ensure that all care planning aligns with the client’s needs, values, and readiness to engage in discussions about their care.

A. A child who has a forehead wound that is bleeding copiously: While bleeding wounds require attention, they are not immediately life-threatening compared to other injuries described.

B. A child who has a compound fracture of the femur and is crying in pain: While painful, a

femur fracture is not typically immediately life-threatening unless it is causing severe bleeding or compromising circulation.

C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake:

These symptoms suggest potential head trauma and require urgent evaluation to assess for intracranial injuries.

D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip: These injuries, while concerning, are not immediately life-threatening compared to the potential head injury described in option C.