Question

A client is in active labor, and as labor progresses, the client becomes irritable and reports feeling increasingly uncomfortable. The client is dilated to 8cm. What is the first action made by the nurse?

A. Encourage the client to push
B. Administer pain medication
C. Assess for the urge to push
D. Check for cervical dilation

Answer 1

The nurse's initial action should be to assess for the urge to push when a client in active labor reports discomfort and is 8 cm dilated. Effective pushing should be coordinated with full cervical dilation to ensure a safe and efficient birth process.

Step-by-step explanation:

When a client is in active labor and reports feeling increasingly uncomfortable with a cervical dilation of 8cm, the first action made by the nurse should be to assess for the urge to push. This assessment is critical because effective pushing should only begin when the cervix is fully dilated to 10 cm to avoid cervical trauma. Pushing too early can also lead to exhaustion and other complications. If the client does have an urge to push and other signs indicating the cervix is fully dilated, such as a 'bloody show' (passage of a small amount of blood or bloody mucus through the vagina), then the nurse can encourage the client to start pushing. If the client does not have an urge to push, other supportive measures can be taken, such as pain management or labor progression monitoring.

Monitoring labor progression is essential to guide the appropriate interventions and provide the necessary support. Checking for cervical dilation might follow if the urge to push is not yet present, to determine how close the client is to complete dilation.