Final answer:
In the second stage of labor, a nurse should monitor contractions and fetal heart rate, provide comfort and support, help with effective positioning, and prepare for newborn delivery while maintaining a safe and supportive environment.
Step-by-step explanation:
A nurse is caring for a patient in the second stage of labor. The most appropriate actions would include monitoring the patient's contractions and fetal heart rate, providing support and encouragement, assisting with positioning for comfort and effective pushing, and preparing for the imminent arrival of the newborn. Safety and support for both mother and baby are paramount in this stage, which involves the expulsion of the baby from the uterus. The second stage of labor is a critical time, and the nurse should ensure a safe and supportive environment to promote a healthy delivery. In the provided scenario, the patient named Janine may have received an IV infusion of Pitocin to assist with labor progression because her contractions were insufficient to dilate the cervix beyond 2 cm, despite being at 41 weeks gestation. It is essential to continue monitoring and support during this stage until the baby is delivered.
Providing emotional support: Offer encouragement and reassurance to the patient during the intense phase of labor.
Assisting with position changes: Encourage the patient to try different positions that may facilitate the descent of the baby.
Monitoring fetal heart rate: Continuously monitor the fetal heart rate to ensure the well-being of the baby.
Guiding and coaching during pushing: Instruct the patient on effective pushing techniques and provide guidance during contractions.
Preparing for delivery: As the baby's head crowns, be prepared for the actual delivery, providing gentle guidance and support.
Ensuring a safe and sterile environment: Maintain a clean and safe environment to reduce the risk of infection.
Communicating with the healthcare team: Keep the healthcare team informed about the progress and any concerns during the second stage of labor.