The nurse is caring for a client in the second stage of labor. What assessment findings indicate that birth is imminent? Select all that apply
1. Drop in blood pressure
2. Increased bloody show
3. Bulging of the perineum
4. Subjective feeling of faintness
5. Uncontrollable urge to bear down
2, 3, 5
Explanation:
1. A drop in blood pressure could be due to blood loss or dehydration. It is not an indication that birth is imminent.
2. Birth is imminent if the woman has increased bloody show.
3. Birth is imminent if the woman has bulging of the perineum.
4. Subjective feeling of faintness can be due to hyperventilation. The nurse needs to coach the client to slow the rate of breathing.
5. Birth is imminent if the woman has an uncontrollable urge to bear down.
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