The nurse is assessing a client who presents to labor and delivery at 36 weeks gestation.

The client reports contractions and vaginal bleeding that started 30 minutes ago.

What is the priority nursing action?

The nurse must apply knowledge of labor stages and parity. Recognizing that a multiparous client in the transition phase of labor often progresses rapidly to delivery is essential for prioritizing preparation for the second stage of labor and birth.

Choice A rationale

Repositioning every three hours is too infrequent for a client in the transition phase. Furthermore, at 9 cm dilation, the priority is preparing for imminent birth rather than implementing a long-term comfort schedule for early labor.

Choice B rationale

Pushing before the cervix is completely dilated at 10 cm can cause cervical edema or lacerations. The client is currently 9 cm dilated, so instructing her to push now is premature and potentially harmful to the cervix.

Choice C rationale

Initial labor education should occur during the latent phase. By the time a client reaches 9 cm dilation, they are in the transition phase and unable to process complex education due to the intensity of labor.

Choice D rationale

A multiparous client (para 5) at 9 cm dilation is likely to progress to complete dilation and birth very quickly. Preparing delivery supplies immediately ensures that the room is ready for the safe arrival of the newborn..

Evaluating a late-preterm client with bleeding and contractions requires knowledge of maternal-fetal triage. Priority is given to assessing fetal well-being and uterine activity to differentiate between labor, placental abruption, or other complications, ensuring the safety of both patients.

Choice A rationale

Digital cervical examinations are contraindicated until the location of the placenta is confirmed via ultrasound. If placenta previa is present, manual assessment can cause catastrophic maternal hemorrhage. Physical assessment must follow the stabilization of fetal and maternal monitoring.

Choice B rationale

Immediate delivery preparation is premature without a confirmed diagnosis. While 36 weeks is near term, the cause of bleeding must be identified first. Delivery may be necessary for abruption, but monitoring is the initial step to determine urgency.

Choice C rationale

Tocolytics are used to delay labor, but they are contraindicated in cases of significant vaginal bleeding or suspected placental abruption. Administering these before confirming the cause of bleeding could mask worsening clinical signs and delay necessary interventions.

Choice D rationale

Applying an external monitor is the priority to evaluate fetal heart rate patterns and uterine contraction frequency. This non-invasive step provides immediate data on fetal distress, which is critical when vaginal bleeding suggests potential placental or cord issues.