Health Promotion and Maintenance
82. A client, who is gravida 1, para 0 at 37 weeks' gestation, is admitted to labor and delivery in active labor. A vaginal examination reveals a footling breech presentation. Which action should the nurse take first?
. Anticipate the need for a cesarean section.
. Apply the fetal heart monitor.
. Place the client in genupectoral position.
. Perform an ultrasound exam.
Test-Taking Tip
Eliminate the interventions that delay getting the client ready for a cesarean section.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Health Promotion and Maintenance
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Answer 1 is correct because the client will need a cesarean section as quickly as possible to avoid a vaginal delivery and possible head entrapment. Answer 2 is incorrect because applying the fetal heart monitor is important, but does not facilitate preparation for the cesarean section. Answer 3 is incorrect because placing the client in genupectoral position is appropriate for a prolapsed cord, not for footling breech presentation. Answer 4 is incorrect because the vaginal examination has already revealed a footling breech; getting an ultrasound is not a priority at this time.