Question

The nurse cares for a patient in labor. The patient suddenly shouts, "I have to push! I have to push!" The nurse determines that the patient is 8 cm dilated. Which of the following actions should the nurse take first?

a. instruct the patient to take a deep breath and bear down
b. apply pressure to the patient's fundus
c. coach the patient in relaxation techniques
d. encourage the patient to pant with pursed lips

Answer 1

When a patient in labor feels the urge to push but is only 8 cm dilated, the nurse should encourage panting with pursed lips to prevent early pushing and potential complications.

Step-by-step explanation:

If a patient in labor states, "I have to push! I have to push!" and is 8 cm dilated, the nurse should first encourage the patient to pant with pursed lips. This is because the patient is not yet fully dilated to 10 cm, which is required for safe pushing during the second stage of labor.

Panting helps to prevent the patient from bearing down too early, which can lead to cervical edema or tearing if the cervix is not fully dilated. It also helps in controlling the urge to push before it is appropriate, thus reducing the risk of complications.