21. A client, who is gravida 4, para 3 at 38 weeks' gestation, is entering the second stage of labor. Which essential action should a nurse perform at this time?
21. A client, who is gravida 4, para 3 at 38 weeks' gestation, is entering the second stage of labor. Which essential action should a nurse perform at this time?
. Prepare the client for an emergency cesarean section.
. Administer 10 units oxytocin IM.
. Administer 800 mcg misoprostol rectally.
. Notify the physician of the client's vaginal exam.
Test-Taking Tip
Remember the four stages of labor and the three phases of the first stage of labor. The important consideration is that the client is a multipara, and the second stage is usually shortened.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
.
Answer 1 is incorrect because there is nothing in the question that indicates a need for an emergency cesarean section. The second stage of labor is from complete dilation to delivery of the neonate. Answer 2 is incorrect because administering oxytocin IM is appropriate after delivery of the placenta to contract the uterus and decrease bleeding. Answer 3 is incorrect because administering a large dose of misoprostol rectally is appropriate after delivery of the placenta to control postpartum hemorrhage. Answer 4 is correct because the second stage of labor is the pushing stage, and a client who is a multipara usually delivers without a long second stage. The nurse should notify the physician of the results of the cervical examination and the need for the physician to come for delivery.