Maternity Nursing: Intrapartum Q 30
A client arrives at the hospital in the second stage of labor. The fetus’ head is crowning, the client is bearing down, and the birth appears imminent. The nurse should:
A. Transfer her immediately by stretcher to the birthing unit.
B. Tell her to breathe through her mouth and not to bear down.
C. Instruct the client to pant during contractions and to breathe through her mouth.
D. Support the perineum with the hand to prevent tearing and tell the client to pant.
Correct Answer: D. Support the perineum with the hand to prevent tearing and tell the client to pant.
Gentle pressure is applied to the baby’s head as it emerges so it is not born too rapidly. The head is never held back, and it should be supported as it emerges so there will be no vaginal lacerations. It is impossible to push and pant at the same time.
Option A: Imminent delivery is when the baby’s head is visible at the vaginal opening during a contraction (crowning). C. A visual inspection of the perineal area should only be done when contractions are less than 5 minutes apart, there is bleeding/fluid discharge, and/or the patient feels the urge to push.
Option B: A visual inspection of the perineal area should only be done when contractions are less than 5 minutes apart, there is bleeding/fluid discharge, and/or the patient feels the urge to push. Do not perform a digital examination to gauge cervical dilation.
Option C: Begin each contraction with two deep breaths. Inhale deeply and exhale slowly through pursed lips. Relax the bottom and push down. Keep the abdominal muscles tight around the baby as she takes another breath. The woman may find herself making throaty sounds. Repeat these steps as long as the contraction lasts.