A nurse is assisting in the care of a client who is in the second stage of labor.
Which of the following findings should the nurse report to the provider?

Choice A is incorrect. Preterm labor is defined as uterine contractions that occur before 37 weeks of gestation. The

client in this case is at 38 weeks of gestation, which is considered term gestation. Therefore, preterm labor is not the

most likely condition the client is experiencing.

Rationale for Choice B

Choice B is partially correct. While bed rest may be recommended for some clients experiencing certain conditions

during pregnancy, it is not the most appropriate intervention for all clients at 38 weeks of gestation. Additionally,

administering medication without knowing the specific condition the client is experiencing is not safe or ethical.

Rationale for Choice C

Choice C is correct. Monitoring contraction frequency and fetal heart rate are two of the most important actions a

nurse can take to assess a client at 38 weeks of gestation. These parameters can provide valuable information about

the client's progress and help to identify any potential problems.

Explanation:

At 38 weeks of gestation, the client is considered to be at term. This means that she is full-term and her baby is ready

to be born. However, even at term, there are a number of conditions that can occur that may require nursing

intervention.

One of the most common conditions that can occur at term is labor. Labor is the process by which the uterus contracts

and dilates to push the baby out of the birth canal. The nurse should monitor the client for signs and symptoms of

labor, such as:

Regular contractions that are becoming stronger and closer together

Bloody show (mucus mixed with blood)

Rupture of membranes (breaking of water)

If the nurse suspects that the client is in labor, she should notify the healthcare provider immediately.

Another condition that can occur at term is preeclampsia. Preeclampsia is a serious condition that can cause high

blood pressure, protein in the urine, and swelling in the face, hands, and feet. If the nurse suspects that the client has

preeclampsia, she should monitor the client's blood pressure, protein levels in the urine, and weight. She should also

notify the healthcare provider immediately.

In addition to monitoring for these specific conditions, the nurse should also perform a general assessment of the

client's health. This includes taking the client's vital signs, checking her abdomen for fetal movement, and listening to

the baby's heartbeat.

By monitoring the client for signs and symptoms of these conditions, the nurse can help to ensure a safe and healthy

delivery for both the mother and the baby.

Therefore, the two most important actions the nurse should take are:

Monitor the client for signs and symptoms of labor and preeclampsia.

Perform a general assessment of the client's health.

The two most important parameters the nurse should monitor are:

Contraction frequency and intensity

Fetal heart rate

By following these steps, the nurse can provide the best possible care for the client and her baby.

Choice A rationale:

Normal progression of labor: After the fetal head is delivered, the shoulders typically follow immediately. The nurse should be prepared to assist with the delivery of the shoulders to ensure a safe and smooth birth process.

Significance of retraction: Retraction of the fetal head against the maternal perineum, also known as the "turtle sign," is a classic indicator of shoulder dystocia. While this sign does not guarantee shoulder dystocia, it warrants immediate preparation for potential management.

Anticipating shoulder dystocia: By anticipating the possibility of shoulder dystocia, the nurse can take proactive measures to minimize risks and facilitate delivery. These measures may include:

Positioning the mother appropriately (e.g., McRoberts maneuver)

• Applying suprapubic pressure
• Performing internal maneuvers (e.g., Rubin's maneuver)
• Breaking the clavicle (in extreme cases)

Choice B rationale:

Ineffective in shoulder dystocia: Encouraging the mother to push during the next contraction is not an effective intervention

for shoulder dystocia. In fact, excessive pushing can worsen the impaction of the shoulders and potentially lead to

complications such as fetal hypoxia, brachial plexus injury, or maternal perineal trauma.

Choice C rationale:

Necessary in confirmed dystocia: Calling for additional medical support is crucial if shoulder dystocia is confirmed. However,

immediate preparation for shoulder delivery should commence without delay, as prompt action is essential to prevent adverse

outcomes.

Choice D rationale:

Secondary concern: While pain relief medication may be administered for maternal comfort, it is not a priority intervention in

this situation. The primary focus should be on managing the potential shoulder dystocia and ensuring the safe delivery of the

baby.