The nurse encounters a woman giving birth at the local mall. What should the nurse do first?
1. Apply counterpressure to the perineum.
2. Ask a bystander for a dry piece of clothing.
3. Visualize the perineum.
4. Determine if the membranes have ruptured.
3
Rationale:
1. This is appropriate if the presenting part is crowning. Counterpressure to the perineum helps prevent perineal lacerations.
2. Prior to birth, some dry cloth object should be obtained to dry the infant and prevent neonatal hypothermia.
3. Inspecting the perineum is the only method of determining whether the client is going to give birth imminently. This is the top priority.
4. This is less important than knowing whether the baby is coming at this time.
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