# A nurse is caring for a primigravida client who is experiencing precipitous labor. The cervix is fully dilated, and the fetal head is crowning. Which nursing intervention should the nurse implement first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543046  
> language: ko  
> subject: Maternal Newborn Health

## 문제

A nurse is caring for a primigravida client who is experiencing precipitous labor. The cervix is fully dilated, and the fetal head is crowning. Which nursing intervention should the nurse implement first?

A 24-year-old primigravida client arrives at the emergency department in active labor. Her contractions began 3 hours ago and are now occurring every 2-3 minutes, lasting 45-60 seconds. Upon examination, the cervix is completely dilated at 10 cm, and the fetal head is visible at the perineum with crowning occurring.

## 보기

1. Encourage the client to push with each contraction to expedite delivery
2. Prepare for immediate transfer to the delivery room
3. Apply gentle pressure to the fetal head to control the delivery **✔ 정답**
4. Position the client in lithotomy position for optimal visualization

**정답: 3**

## 해설

In precipitous labor with crowning, the priority is to control delivery to prevent maternal perineal trauma and fetal injury. Applying gentle pressure to the fetal head (Ritgen maneuver) slows expulsion, while other options are less immediate or inappropriate.

## 심화 해설

Understanding Precipitous Labor and Imminent Delivery

In precipitous labor, defined as labor lasting less than 3 hours from the onset of regular contractions to delivery, the rapid descent and expulsion of the fetus can lead to significant maternal and neonatal complications if not managed with precise, controlled interventions. When the cervix is fully dilated (10 cm) and crowning is occurring—meaning the fetal head is visible at the perineum and does not retract between contractions—delivery is imminent. The primary physiological risk at this moment is uncontrolled, explosive delivery of the head, which can cause severe perineal lacerations (third- and fourth-degree tears) in the mother and increase the risk of fetal intracranial hemorrhage or shoulder dystocia. The evidence on interfacility transport underscores this urgency, noting that for patients in advanced labor, delivery may be too imminent to safely transfer, reinforcing that immediate, site-specific delivery management is the only safe option [1].

Analysis of Intervention Options

The nurse must prioritize an intervention that directly mitigates the risk of trauma from an uncontrolled birth.

| Option | Rationale and Clinical Judgment |
| --- | --- |
| 1. Encourage the client to push with each contraction to expedite delivery. | This is contraindicated. Active, forceful pushing during crowning overcomes the natural, gradual stretching of the perineum by the fetal head. This accelerates expulsion and dramatically increases the risk of severe perineal trauma and fetal injury. The goal is a slow, controlled delivery, not an expedited one. |
| 2. Prepare for immediate transfer to the delivery room. | Moving a client when the fetal head is crowning is dangerous and contraindicated. Transport at this stage risks an uncontrolled delivery during transit, falls, and fetal injury. The research on maternal-fetal transport explicitly highlights that delivery may be "too imminent to transfer," and the clinical scenario demands immediate delivery at the bedside, not relocation [1]. |
| 3. Apply gentle pressure to the fetal head to control the delivery. | This is the correct and priority intervention. The technique, often called the Ritgen maneuver (modified), involves applying gentle, counter-pressure with one hand on the fetal occiput while the other hand provides support to the perineum. This controls the speed of head extension and delivery, allowing for a slow, controlled birth between contractions. This directly prevents explosive delivery, protecting the perineum and reducing fetal cranial trauma. It is the definitive bedside action to manage an imminent, uncontrolled birth. |
| 4. Position the client in lithotomy position for optimal visualization. | While lithotomy is a common delivery position, it is not the priority action and can be physiologically disadvantageous. It may compress the aorta and vena cava, reducing uteroplacental perfusion, and it narrows the pelvic outlet compared to upright or lateral positions. More critically, repositioning a client who is crowning delays the essential intervention of controlling the fetal head and could stimulate further descent. The immediate need is to control the delivery, not optimize visualization. |

The Physiological Basis for Controlled Delivery

The fetal skull is designed to mold during descent through the birth canal. During crowning, the gradual stretching of the perineum by the presenting part stimulates a reflexive surge of endogenous oxytocin (the Ferguson reflex), which strengthens expulsive contractions. If these powerful contractions are not counterbalanced by controlled, gentle counter-pressure on the fetal head, the forces can eject the fetus rapidly. This sudden pressure change from the intrauterine environment to atmospheric pressure, combined with rapid, uncompensated skull decompression, risks tearing the tentorium cerebelli and causing subdural or subarachnoid hemorrhage. For the mother, the rapid overstretching of the perineal muscles and fascia beyond their viscoelastic capacity results in tearing rather than gradual thinning. The nurse’s application of gentle pressure directly opposes these expulsive forces, safeguarding both patients. The critical nature of this moment is mirrored in transport decisions; the study on maternal-fetal transport programs identifies that for patients with advanced cervical dilation and imminent delivery, the risk of delivery en route or immediately upon arrival is high, making on-site management with these precise skills the standard of care [1].References (research sources)

- [1]Assessing the Risk of Interfacility Transport in Pregnant Patients Due to Progression of Labor: Lessons From a Specialized Maternal-Fetal Transport Program.Research articleLardaro T, Balaji A, Yang D, Kuhn D, Glober N, Brent CM, Couturier K, Breyre A, Vaizer J, Hunter BR. (2024) · DOI: 10.7759/cureus.70542

## 임상 시나리오

Clinical Practice Guide: Managing Imminent Delivery in Precipitous Labor

Key Actions for the Nurse

- **Stay with the client** and summon help immediately; do not attempt transfer when crowning is present.

- **Apply gentle, counter-pressure** on the advancing fetal head using the palm against the perineum (modified Ritgen maneuver) to promote slow, controlled extension.

- **Instruct the client to pant or blow** through contractions instead of pushing to reduce expulsive force.

- **Support the perineum** with a warm compress to enhance tissue elasticity and reduce tearing risk.

Critical Rationale

Uncontrolled, explosive delivery of the head is the primary preventable cause of third- and fourth-degree perineal lacerations and fetal complications such as intracranial hemorrhage. Gentle perineal pressure directly mitigates this risk by slowing the emergence of the head and allowing gradual perineal stretching. This intervention takes absolute priority over positioning or active pushing, which can accelerate trauma.

Safety Considerations

- If delivery occurs outside a controlled setting, place the newborn skin-to-skin and dry immediately to prevent hypothermia.

- Do not pull on the fetal head; allow spontaneous restitution and external rotation.

- Assess for signs of shoulder dystocia after head delivery and be prepared to apply suprapubic pressure if indicated.

## 핵심 개념

- **precipitous labor** — Labor lasting less than 3 hours from onset of regular contractions to delivery, associated with increased risk of maternal and neonatal complications.
- **crowning** — The stage of labor when the fetal head is visible at the vaginal opening and does not retract between contractions, indicating imminent delivery.
- **Ritgen maneuver** — A technique involving application of gentle upward pressure on the fetal chin through the perineum to control extension of the head during delivery.

## 같은 주제 문제

- [A nurse is assessing a 28-year-old primigravida client who presents to the labor and deliv…](https://mymerci.kr/pages/nclex_q.php?qn_id=543042)
- [A nurse is assessing a primigravida client who arrived at the labor and delivery unit 30 m…](https://mymerci.kr/pages/nclex_q.php?qn_id=543043)
- [A nurse is caring for a 30-year-old primigravida client at 39 weeks gestation who is exper…](https://mymerci.kr/pages/nclex_q.php?qn_id=543044)
- [A nurse is caring for a 22-year-old primigravida client at 37 weeks gestation who is exper…](https://mymerci.kr/pages/nclex_q.php?qn_id=543045)
- [A nurse is caring for a primigravida client who is experiencing precipitous labor. What is…](https://mymerci.kr/pages/nclex_q.php?qn_id=543047)
- [A primigravida client at 38 weeks gestation arrives at the emergency department with stron…](https://mymerci.kr/pages/nclex_q.php?qn_id=543048)
- [A 30-year-old primigravida at 40 weeks gestation arrives at the emergency department stati…](https://mymerci.kr/pages/nclex_q.php?qn_id=543049)
- [A primigravida client at 38 weeks gestation arrives at the emergency department with stron…](https://mymerci.kr/pages/nclex_q.php?qn_id=543050)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._