MEDizzy - A nurse is caring for a 30-weeks-pregnant client who is

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Care of Childbearing Families

A nurse is caring for a 30-weeks-pregnant client who is having contractions every 11 /2 to 2 minutes with spontaneous rupture of membranes 2 hours ago. The client’s cervix is 8 cm dilated, and her cervix is 100% effaced. The nurse determines that delivery is imminent. Which nursing action is the most important at this time?

ExplanationThe most important component of the client’s care at this time is to notify the neonatal team of the delivery because they will be needed for respiratory support and possible resuscitation. It is too late to administer a tocolytic agent. A cesarean birth is indicated if there are other obstetrical needs. Teaching is important but is not appropriate at this time.