A female is gravida 4,para 3 and is in labour room. After a vaginal examination it is determined that the foetus is at +3 station. The most appropriate nursing action is:

Question

Question

This question was previously asked in

KGMU Nursing Officer 2023 Memory-Based Previous Year Paper

Answer 1

Correct Answer: Prepare her for immediate delivery

Rationale:

The foetus at +3 station indicates that it is very low in the pelvis and nearing crowning. This stage is typically observed during the second stage of labor, when delivery is imminent. Immediate preparation for delivery is critical to ensure a safe outcome for both the mother and the baby.
At this station, the baby’s head is visible, and the mother may begin to feel the urge to push. Delaying action at this point could result in complications, such as a precipitous delivery or trauma to the mother or baby.
The nurse's role is to prepare the labor room for immediate delivery, ensure sterile equipment is ready, and notify the healthcare provider or midwife to assist with the delivery.
Additionally, monitoring maternal and fetal well-being during this critical phase is essential to identify any potential complications, such as fetal distress or perineal trauma.

Explanation of Other Options:

Check for prolapsed cord

Rationale: A prolapsed cord occurs when the umbilical cord slips ahead of the presenting part of the fetus, cutting off oxygen supply. While this is a medical emergency, it is not indicated in this scenario because the fetus is already at +3 station, meaning the presenting part (likely the head) is well-engaged in the pelvis, making cord prolapse highly unlikely.

Start oxytocin drip

Rationale: Oxytocin is used to stimulate or augment uterine contractions. However, at +3 station, the labor is in an advanced stage, and the uterus is likely contracting effectively. Initiating oxytocin at this point is unnecessary and could increase the risk of uterine hyperstimulation, leading to complications such as fetal distress.

Continue to observe female’s uterine contractions

Rationale: While observation is a critical aspect of labor management, at +3 station, passive observation alone is not sufficient. The imminent nature of delivery requires active preparation, as delaying action could result in complications for both the mother and the baby.

Conclusion:

The most appropriate action in this scenario is to prepare the mother for immediate delivery. This ensures that all necessary equipment and personnel are ready to manage the delivery safely. The other options either do not address the urgency of the situation or are not relevant given the station and stage of labor.