Question

A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time?

1) Assess the fetal heart rate between contractions every 60 minutes.
2) Encourage the woman to grunt during contractions.
3) Assess the pulse and respirations of the mother every 5 minutes.
4) Position the woman on her back with her knees on her chest.

Answer 1

The appropriate nursing action during the second stage of labor is to encourage controlled pushing such as grunting and to monitor fetal and maternal well-being closely.

Step-by-step explanation:

When a woman is in the second stage of labor with a strong urge to push, the appropriate action by the nurse would be to encourage the woman to push effectively during contractions and monitor both maternal and fetal well-being.

Specifically, encouraging grunting or controlled pushing can help the woman use her contractions effectively to push the baby out.

Additionally, it's important to regularly assess the fetal heart rate to ensure the fetus is coping well with the labor, and for this, the fetal heart rate should be checked more frequently than every 60 minutes, possibly after every contraction.