Final answer:
During stage two of labor, the nurse would encourage the client to push with each contraction. The correct option is D.The nurse should instruct the client to pant and not push if they feel the urge to push at 8 cm dilation to prevent potential complications until full dilation occurs.
Step-by-step explanation:
During stage two of labor, when the client is 8 cm dilated and feels the need to push, the nurse's first action would be to encourage the client to push with each contraction. This is because the client is likely in the active second stage of labor, during which pushing can help facilitate the baby's delivery. Instructing the client to pant and not push (option a) is not the appropriate action at this stage. While preparing the client for immediate delivery (option b) and calling for additional medical assistance (option c) may be necessary, the immediate action is to encourage the client to push.
The nurse should instruct the client to pant and not push if they feel the urge to push at 8 cm dilation to prevent potential complications until full dilation occurs.
If a client in active labor exclaims "I have to push!" and is determined to be 8 cm dilated, the appropriate action for the nurse to take first is a) Instruct the client to pant and not push.
Full cervical dilation to 10 cm is necessary before the client should begin pushing to prevent potential complications such as cervical lacerations or undue stress on the fetus. Pushing prematurely at 8 cm dilation could contribute to these risks. Therefore, the nurse should instruct the client to use controlled breathing techniques, such as panting, which helps regulate the urge to push and minimizes the risk of beginning the pushing phase too early.
Once the cervix is fully dilated to 10 cm, the client will be encouraged to push with each contraction to aid in the delivery of the baby during the second stage of labor.