The charge nurse has received the shift change report. Which patient requires immediate intervention?

Question

1. Multip at 6 cm undergoing induction of labor, strong contractions every 3 minutes
2. Primip at 4 cm whose fetus is in a longitudinal lie with a cephalic presentation
3. Multip at 10 cm and fetus at +2 station experiencing a strong expulsion urge
4. Primip at 3 cm screaming in fear because her mother died during childbirth

Answer 1

4
Rationale 1: Strong contractions every 3 minutes constitute an adequate labor pattern during induction of labor. This patient is experiencing no complications.
Rationale 2: Longitudinal lie with cephalic presentation is a head-down position. This is expected.
Rationale 3: Ten cm is fully dilated; a +2 station is low in the pelvis. A strong expulsion urge is the urge to push, which will facilitate the birth of the child. These are expected.
Rationale 4: This patient is most likely fearful that she will die during labor because her mother died during childbirth. This patient requires education and a great deal of support, and is therefore the top priority.