72. A client, who is gravida 6, para 5, has a sudden urge to push. A nurse performs a sterile vaginal examination and finds that the cervix is completely dilated and the fetus is at a +2 station. Which nursing intervention is most important at this time?
. Call the physician to come for delivery and place the client in high Fowler's position.
. Call the physician for delivery, and then put pressure against the fetus' head until the physician arrives for delivery.
. Call the physician for delivery, and then gently pull on the fetus' head until it is delivered.
. Call the physician for delivery, apply gentle pressure to the perineum and guide the fetus' head as it is delivered.
Test-Taking Tip
Calling the physician is the first thing the nurse should do and is a part of all the answers, but management of a precipitous delivery is the key concept in this question. Controlling the fetal head, but not placing pressure against (Answer 2) and not pulling (Answer 3) on the head, during delivery is the nurse's responsibility.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
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Answer 1 is incorrect because placing the client in high Fowler's position will facilitate the delivery and does not prevent perineal tearing during a precipitous delivery. Answer 2 is incorrect because putting pressure against the fetus' head until the physician arrives for delivery is an inappropriate method to manage a precipitous delivery. Answer 3 is incorrect because gently pulling on the fetus' head until it is delivered is not an appropriate method for managing a precipitous delivery, and can cause fetal damage during delivery. Nurses are expected to prevent damage from a precipitous delivery, but not to facilitate the delivery by pulling on the fetal head. Answer 4 is correct because calling the physician for delivery, applying gentle pressure to the perineum, and guiding the fetus' head as it is delivered is the proper method for managing a precipitous delivery. By using gentle pressure on the perineum, the head is controlled during delivery, and the chance of perineal tearing is reduced.