The nurse is caring for a laboring woman, G3 P2, who was examined 15 minutes ago.
Her cervix was 8 cm dilated and 90% effaced.
She now states she is feeling strong pressure in her rectum and wants to move her bowels.
Which of the following action should the nurse perform first?
Perform a vaginal exam.
Encourage the patient to push.
Notify the MD.
Offer the patient the bedpan.
The Correct Answer is A
Choice A rationale
Strong rectal pressure indicates advanced labor and potential imminent delivery, requiring immediate assessment of cervical dilation to ensure appropriate intervention and prevent complications.
Choice B rationale
Encouraging the patient to push without confirming cervical dilation could lead to cervical trauma or delivery complications if dilation is not complete, making this action inappropriate.
Choice C rationale
Notifying the MD without first assessing cervical dilation may cause unnecessary delay in intervention, potentially leading to complications during labor and delivery if the patient is fully dilated.
Choice D rationale
Offering the patient the bedpan when she feels strong rectal pressure can increase the risk of delivering the baby in an inappropriate setting, as the rectal pressure suggests imminent birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Notifying the provider is important but does not address the immediate need to assess the patient's progress and readiness for delivery. A direct intervention is required to determine the next steps.
Choice B rationale
Performing a sterile vaginal exam allows the nurse to assess cervical dilation and effacement, fetal station, and presentation, which are crucial to determine if the patient is ready to push and proceed with delivery.
Choice C rationale
Supportive words and care are essential for patient comfort, but they do not provide the necessary assessment to determine the patient's progress in labor or readiness for pushing.
Choice D rationale
Monitoring the fetal heart rate tracing is important for assessing fetal well-being but does not specifically address the patient's readiness to push or her labor progress.
Correct Answer is D
Explanation
Choice A rationale
Placental insufficiency leads to late decelerations due to diminished blood flow, resulting in gradual decreases in fetal heart rate. This differs from the abrupt changes seen with cord compression.
Choice B rationale
Abruption manifests with symptoms such as painful bleeding and uterine tenderness, rather than specific heart rate patterns like those caused by cord compression.
Choice C rationale
Head compression produces early decelerations with a characteristic mirror image of contractions, unlike the abrupt heart rate drops seen with cord compression.
Choice D rationale
Cord compression results in variable decelerations, which are abrupt decreases in fetal heart rate due to intermittent reductions in oxygen supply. This matches the tracing pattern described.
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