A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?
A.
Observe for the presence of a nuchal cord.
B.
Prepare to administer oxytocin.
C.
Observe for crowning.
D.
Apply fundal pressure.
The Correct Answer and Explanation is:
The correct answer is:
C. Observe for crowning.
Explanation:
In the context of labor and delivery, the terms used to describe the fetal station refer to the position of the presenting part of the fetus (usually the head) in relation to the mother’s pelvis. The station is measured in centimeters above or below the ischial spines, which are bony landmarks in the pelvis. A station of 0 means the fetal head is at the level of the ischial spines. A positive number indicates the head is below the ischial spines and closer to delivery, while a negative number indicates it is above the ischial spines.
In this scenario, the fetal head is at a +3 station, meaning it is well below the ischial spines and very close to the perineum. This position indicates that the baby is almost ready for delivery. At +3 station, crowning is imminent. Crowning occurs when the widest part of the baby’s head is visible at the vaginal opening, and this typically signals that the baby is about to be born.
Option A: Observe for the presence of a nuchal cord.
- While observing for a nuchal cord (a situation where the umbilical cord is wrapped around the baby’s neck) is important, it is usually assessed after the head is delivered or during crowning. This action would be more appropriate after the nurse has observed crowning.
Option B: Prepare to administer oxytocin.
- Oxytocin is often administered to strengthen contractions or to manage postpartum hemorrhage, but it is not typically administered at this stage of labor when the baby is at +3 station and delivery is imminent.
Option D: Apply fundal pressure.
- Fundal pressure is not a recommended or standard practice during delivery due to the risk of causing complications such as uterine rupture or fetal distress. It is generally not advisable, especially when the baby is so close to delivery.
Therefore, the nurse’s priority action at this point should be to observe for crowning, as this will indicate that the birth is imminent and the nurse should prepare for the delivery of the baby. This includes positioning the mother appropriately, ensuring the delivery area is ready, and being prepared to assist with the birth as soon as crowning occurs.