10. A client, who is gravida 3, para 2, is admitted to labor and delivery. A sterile vaginal examination reveals that the client's cervix is 9 to 10 cm dilated, 100% effaced, and a +2 station. Which action should the nurse take first?
10. A client, who is gravida 3, para 2, is admitted to labor and delivery. A sterile vaginal examination reveals that the client's cervix is 9 to 10 cm dilated, 100% effaced, and a +2 station. Which action should the nurse take first?
. Administer IV pain relief.
. Prepare the client for delivery.
. Administer fluid bolus.
. Place client in knee-chest position.
Test-Taking Tip
The most important factor to consider is the number of previous deliveries. If the client is having her first baby, the priorities may be different than with the third baby. Clients who are multiparous usually deliver more quickly than the clients who are primigravida.
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
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Answer 1 is incorrect because this client is a multipara and is very close to delivery. Administration of IV pain relief is not a priority, and is not appropriate immediately before delivery. Answer 2 is correct because this client is a multipara and is very close to delivery. Preparing the client for delivery is the most important nursing action at this time. Answer 3 is incorrect because there are no risk factors or problems that indicate that this client needs a fluid bolus. Answer 4 is incorrect because there is no indication for placing this client in knee-chest position. This position is used for cord prolapse, not for delivery.