205k views
3 votes
A client in active labor shouts, 'I HAVE TO PUSH!' The nurse determines the client is 8cm dilated. What is the first action the nurse should take?"

A. Prepare for delivery
B. Encourage the client to push
C. Perform a cervical exam
D. Call the healthcare provide

User Sarvasana
by
7.6k points

1 Answer

3 votes

Final answer:

The nurse's first action should be to perform a cervical exam to determine if full dilation has occurred before the client begins pushing. Encouraging the client to push before the cervix is fully dilated can cause complications.

Step-by-step explanation:

The client in active labor expresses the need to push but is found to be 8cm dilated. The first action the nurse should take is C. Perform a cervical exam. This will determine if the cervix is fully dilated to 10 cm, which is necessary before the client should begin pushing to avoid potential complications such as cervical tearing. Until the cervix is fully dilated, the client should be encouraged to avoid pushing, and other measures can be taken to manage their comfort and the progression of labor. It is during the second stage of labor that the baby is expelled from the uterus through contractions and pushing, but full cervical dilation is crucial before this phase can safely proceed.Once the cervix is fully dilated, the healthcare provider can be called and preparations for delivery can begin. If labor stalls before stage two is reached, synthetic oxytocin, known as Pitocin, may be administered to restart and maintain labor progression.

User Teekin
by
7.7k points