Difficulty: Medium
Average Score: 80%
Simulated
Passage / Scenario
Multiparous woman at 5 cm dilated, 50% effaced, 1+ station, with urge to have a bowel movement.The nurse is in the process of admitting a multiparous woman to labor and delivery from the triage area. One hour ago her vaginal exam was 5 cm dilated, 50% effaced, 1+ station. While completing your review of her prenatal record and completing the admission Questionnaire, she tells you she has an urge to have a bowel movement. The priority nursing intervention is to:
Correct answer
D
Rationale
The urge to have a bowel movement suggests imminent delivery, requiring a vaginal exam to assess labor progress.