A client tells the nurse that her contractions are occurring ...

[Yi-Chen]

A client tells the nurse that her contractions are occurring every 2 minutes and lasting 60 seconds for the last hour. What action should the nurse take first?
 
  a. Assess cervical dilation and effacement.
  b. Obtain a complete health history.
  c. Perform Leopold's maneuvers.
  d. Notify the physician.

Question 2

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?
 
  a. The fetal head is felt at 0 station during vaginal examination.
  b. Bloody mucus discharge increases.
  c. The vulva bulges and encircles the fetal head.
  d. The membranes rupture during a contraction.

[scikid]

Answer to Question 1

A
These contractions are characteristic of the first stage of labor, so the nurse should assess cervical dilation and effacement first. While obtaining a complete health history and performing Leopold's maneuvers are important nursing interventions, establishing cervical dilation and effacement is a higher priority in this situation. The health care provider should be notified after the nurse assesses cervical dilation and effacement.

Answer to Question 2

C
Feedback
A Birth of the head occurs when the station is +4 . A 0 station indicates
engagement.
B Bloody show occurs throughout the labor process and is not an indication of an
imminent birth.
C A bulging vulva that encircles the fetal head describes crowning, which occurs
shortly before birth.
D Rupture of membranes can occur at any time during the labor process and does
not indicate an imminent birth.