A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?
Explanation & Rationale
A. Cut the umbilical cord: Cutting the umbilical cord occurs after the newborn is fully delivered and the cord is clamped. It is not a priority action during rapid labor before delivery is complete. B. Apply perineal pressure to the emerging fetal head: Applying controlled perineal pressure can help support the perineum and reduce tearing. However, it must be done carefully and often under guidance. While important, preventing tearing encompasses more than just pressure application. C. Prevent the perineum from tearing: Protecting the perineum during rapid labor is the priority to minimize maternal injury. This includes supporting the perineum, controlling the speed of delivery, and using techniques to reduce trauma, which directly impacts maternal outcomes. D. Promote delivery of the placenta: Delivery of the placenta occurs after the baby is born. At the stage of rapidly progressing labor with imminent birth, managing delivery safely takes precedence over placental delivery.