Maternity Nursing Q 200
A client who’s admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time?
A. Placing the client in bed to begin fetal monitoring.
B. Preparing for immediate delivery.
C. Checking for ruptured membranes.
D. Providing comfort measures.
Correct Answer: B. Preparing for immediate delivery.
This question requires an understanding of station as part of the intrapartum assessment process. Based on the client’s assessment findings, this client is ready for delivery, which is the nurse’s top priority.
Option A: Fetal heart rate monitoring may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem. Fetal heart rate monitoring also can help prevent treatments that are not needed.
Option C: The membranes can break by themselves. This is called a spontaneous rupture of the membranes. It most often happens after active labor has started.
Option D: Comfort measures may be given to the woman after ensuring all necessary measures to help her deliver successfully.