Question

A client in active labor suddenly shouts, I have to push! I have to push! The nurse determines the client is 8 cm dilated. Which action does the nurse take first?

a) Instruct the client to start pushing immediately
b) Call for assistance and prepare for delivery
c) Administer pain medication to the client
d) Check the fetal heart rate

Answer 1

The nurse should first check the fetal heart rate.

Step-by-step explanation:

When a client in active labor suddenly shouts, 'I have to push! I have to push!' and the nurse determines that the client is 8 cm dilated, the first action the nurse should take is to check the fetal heart rate (d). This is because a sudden urge to push can indicate that the baby is descending into the birth canal, and checking the fetal heart rate will help ensure the well-being of the baby.