A woman is in the second stage of labor with a strong urge to push.
Which of the following actions by the nurse is appropriate at this time? Check all that apply.

Choice A rationale

While nonpharmacologic methods like hydrotherapy or slow paced breathing may encourage a more controlled and potentially slower progression of labor, this is not considered the major advantage. Labor duration is highly variable, and excessively slow labor can increase the risk of maternal fatigue, infection, and fetal distress, potentially leading to interventions like augmentation or Cesarean birth. The primary benefit centers on avoiding drug side effects.

Choice B rationale

Nonpharmacologic pain management, such as massage, guided imagery, or relaxation techniques, aims to decrease the perception of pain, increase the woman's coping ability, and promote comfort, but it does not typically eliminate the pain associated with uterine contractions and cervical dilation, which is a physiologic process. Complete pain relief is more commonly associated with effective regional anesthesia.

Choice C rationale

Nonpharmacologic methods generally allow the woman to remain alert and actively participate in the birth process, which is a benefit, but some techniques, like hypnosis or deep relaxation, may cause a semi-conscious state. Also, even with pharmacologic methods like low-dose opioids, women can often remain quite alert. The greatest single benefit is the lack of drug-related effects on the fetus.

Choice D rationale

The primary and most significant advantage of using nonpharmacologic pain management strategies during labor, such as effleurage, position changes, or breathing techniques, is the complete absence of systemic drug exposure to the fetus, thereby eliminating all risks of neonatal respiratory depression, decreased alertness, or potential long term effects associated with medications.

Choice A rationale

Instructing the mother to push with contractions and rest in between is the correct approach to conserve her energy and maximize the effectiveness of pushing efforts during the second stage of labor. This technique, often called open-glottis pushing, allows for physiological rest and prevents maternal exhaustion, optimizing oxygen exchange.

Choice B rationale

Administering prophylactic oxygen to the mother during pushing is not routinely recommended and has no established benefit for maternal strength or fetal well-being in an otherwise healthy labor. Oxygen is administered only if the mother shows signs of distress or if the fetal heart rate tracing indicates non-reassuring changes.

Choice C rationale

Assessing the fetal heart rate (FHR) every 5 to 15 minutes is the standard of care for a low-risk woman during the second stage of labor. This frequent assessment is critical for monitoring the fetus's response to the stress of uterine contractions and pushing, allowing for timely intervention if signs of distress emerge.

Choice D rationale

Performing a sterile vaginal examination (SVE) to check for dilation in a woman with a strong urge to push is generally unnecessary once the woman is in the second stage of labor, indicating full dilation. An SVE is performed to assess fetal station, position, and to confirm complete dilation, not as a primary action when pushing has already commenced.

Choice E rationale

Notifying the provider that the woman is having the urge to push may not be necessary if the provider is already aware of the labor progression and is present or immediately available. The primary actions are the direct care and support of the laboring woman, and notification depends on the provider's typical practice and proximity.