4:25 PM
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Ms. K. arrives at the birthing center in active labor. On examination, the cervix is 5 cm dilated membranes intact and bulging, and the presenting part at – 1 station. Ms. K asks if she can go for a walk. What is the best response for the nurse to give?
a. “I think it would be best for you to remain in bed at this time because of the risk of cord prolapse.”
b. “It’s fine for you to walk, but please stay nearby. If you feel a gush of fluid, I will need to check you and your baby.”
b. “It’s fine for you to walk, but please stay nearby. If you feel a gush of fluid, I will need to check you and your baby.”
c. “It will be fine for you to walk because that will assist the natural body forces to bring the baby down the birth canal.
d. “I would be glad to get you a bean bag chair or rocker instead.”
Correct Answer B:. Although there is always some risk of complications when membranes rupture, it is safe for Ms. K. to ambulate as long as she is rechecked if rupture of membranes occur.
Correct Answer B:. Although there is always some risk of complications when membranes rupture, it is safe for Ms. K. to ambulate as long as she is rechecked if rupture of membranes occur.
Although cord prolapse can occur when the presenting part is not fully engaged, the incidence is highest with malpresentation, grand multiparity, multiple gestation, and low birthweight.
Although ambulation does support natural labor progress, this response is not the best one without anticipatory guidance.
Although the nurse may not feel comfortable allowing Ms. K. to walk, this response does not provide the client with any rationale for the nurse’s response and is therefore inappropriate.
Posted in: MCN NCLEX
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