The client is multiparous, fully dilated, and verbalizing the sensation of imminent birth ("the baby is coming"). This combination of factors strongly suggests the second stage of labor is progressing rapidly and birth is imminent. The nurse's immediate priority is to perform a rapid assessment to validate the client's statement. Inspecting the perineum for bulging or crowning of the fetal head is the most direct and definitive way to confirm this. This visual assessment will guide the nurse's next immediate actions, such as calling for assistance, providing perineal support, and preparing for an emergency delivery if the provider is not present.

B. Time the contractions.

Timing contractions is a key assessment during the first stage of labor but is a lower priority when birth is imminent in the second stage.

C. Prepare a sterile area for delivery.

This is an important intervention, but it must follow an assessment. The nurse must first confirm that birth is imminent before preparing the area.

D. Auscultate for fetal heart rate (FHR).

While monitoring FHR is crucial, visually confirming an impending birth takes precedence to prevent an uncontrolled delivery and ensure the safety of both mother and baby.

1. Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2020). Maternity & women's health care (12th ed.). Elsevier. In Chapter 17, "Nursing Care During Labor and Birth," the section on the Second Stage of Labor emphasizes that when a woman has a strong urge to push, the nurse should assess for perineal bulging and crowning as signs of imminent birth (pp. 408-409).

2. Durham, R. F., & Chapman, L. (2019). Maternal-newborn nursing: The critical components of nursing care (3rd ed.). F.A. Davis Company. Chapter 10, "Nursing Care During Labor and Birth," states that if a woman says, "The baby is coming," the nurse's first action should be to assess the perineum for crowning to prepare for imminent birth (p. 221, "Nursing Actions for Imminent Birth").

3. Ricci, S. S., Kyle, T., & Carman, S. (2021). Maternity and pediatric nursing (4th ed.). Wolters Kluwer. Chapter 14, "Nursing Management During Labor and Birth," details the assessment during the second stage of labor, prioritizing the observation of perineal bulging and the visualization of the fetal head as indicators for immediate delivery preparations (p. 512).