A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take?

Question

Quizplus · Accepted Answer

Precipitous birth occurs when labor lasts <3 hours from contraction onset until birth. Signs of imminent birth include involuntary pushing/bearing down with contractions, grunting, or report of sensations of having a bowel movement. If a client arrives at the hospital in second-stage labor (ie, pushing), the nurse rapidly assesses whether birth is imminent by applying gloves and observing the perineum for bulging or crowning of the presenting fetal part (Option A). If the health care provider is not present, the nurse stays with the client, ensures safe client positioning (eg, not standing or on the toilet), and is prepared to act as a birth attendant. The nurse may direct others to perform needed actions (eg, contact provider, assess fetal heart tones, initiate IV access). (Option B) Large-bore IV access (ie, 18G or larger) is helpful for administrating oxytocin in the immediate postpartum period. However, the nurse first confirms that birth is not imminent before performing other actions. (Option C) Notifying the anesthesia provider would be appropriate after confirming that birth is not imminent and performing other nursing actions to ensure client and fetal well-being (eg, assessing fetal heart tones, initiating IV access). (Option D) The nurse should assess fetal heart tones and perform other interventions after determining that birth is not imminent. Educational objective: Precipitous birth is defined as <3 hours of labor from contraction onset until birth. When a client arrives at the hospital in second-stage labor, the nurse rapidly assesses whether birth is imminent before performing other interventions.

A Client, Gravida 4 Para 3, at 38 Weeks Gestation