You are in the process of admitting a multiparous woman to labor and delivery from the triage area. One hour ago her vaginal exam was 4/70/0
While completing your review of her prenatal record and completing the admission questionnaire, she tells you she has an urge to have a bowel movement and feels like pushing. Your priority nursing intervention is to:a. Reassure the patient and rapidly complete the admission.b. Assist your patient to the bathroom to have a bowel movement.c. Assess the fetal heart rate and uterine contractions.d. Perform a vaginal exam.
ANS: d
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a. Completing the admission paperwork is not a priority when birth may be imminent.
b. The urge to have a bowel movement is probably related to fetal descent and complete dilation rather than the patient needing to have a bowel movement.
c. Doing a vaginal exam is the first priority as birth may be imminent.
d. Perform a vaginal exam to assess the progress of labor. The urge to have a bowel movement and feeling like pushing indicate that birth may be imminent.
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