A multipara is having intense uterine contractions with little uterine relaxation between contractions. Vaginal examination reveals rapid cervical dilation and fetal descent. The nurse should:
1. Notify the physician of these findings.
2. Place the woman in knee–chest position.
3. Turn off the lights to make it easier for the woman to relax.
4. Assemble supplies to prepare for a cesarean birth.
1
Rationale:
1. This client is exhibiting manifestations of a precipitous birth. The best action by the nurse is to notify the physician and prepare for delivery.
2. This client is exhibiting manifestations of a precipitous birth. Placing the woman in a knee–chest position might be necessary if the fetus is in a persistent occiput posterior position and labor is arrested, but there is no indication of this in the case presented.
3. This client is exhibiting manifestations of a precipitous birth. At this stage of labor, as described, turning the lights off so that relaxation is enhanced would not be appropriate.
4. This client is exhibiting manifestations of a precipitous birth. There is no indication of fetal distress, so preparing for a cesarean is not appropriate.
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