A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes.

She is groaning and perspiring excessively; she states that she did not attend childbirth classes.

The most important nursing action is to:

Choice A rationale

Oxytocics are primarily smooth muscle stimulants that act on the uterine fundus to cause firm, sustained contractions. While a contracted uterus helps prevent bacterial entry into open blood vessels, the primary purpose of oxytocics after birth is mechanical, not antimicrobial, and therefore they are not administered to prevent infection.

Choice B rationale

Oxytocics stimulate intense uterine contractions, which can be uncomfortable or painful for the woman. They are administered for physiological necessity, not to facilitate rest or relaxation; analgesics or other supportive measures are used for those goals.

Choice C rationale

Oxytocin stimulates powerful contractions of the myometrium, which causes the uterus to clamp down on the blood vessels that supplied the placenta. This contraction is vital for mechanically compressing the uterine blood vessels at the placental site, which prevents or controls postpartum hemorrhage due to uterine atony.

Choice D rationale

Oxytocin administration causes strong uterine cramping as the uterus contracts, which can actually increase postpartum pain. Pain relief is managed through methods like analgesics, not through the administration of an oxytocic agent, which is a key pharmacological intervention to reduce bleeding.

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.